Water Testing: National Testing Labs Watercheck Analysis

Please complete our Beverage Company Profile Form below.

All fields marked in RED are required.

Company Name:
Mailing Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
Contact Name:
Email Address:

Additional Bottled Water & Beverage Information

Status (check one)	Current Bottler Current Bulk Water Supplier Current Distributor Prospective Bottler or Bulk Supplier

Types of Products (check all that apply)	Bottled Water Soft-Drinks Juices & Flavored Beverages Alcoholic Beverages

Type of Bottled Water Products (check all that apply)	Distilled Purified Spring RO Mineral	Drinking Remineralized Fluoridated Artesian Other

Complete the following information for "each" of your sources.

Source #1

Source Name:

Source Type:
Other (specify):

Treatment at Source: (prior to tanker or distribution to plant):


Source water distribution to plant:


Source Annual Testing Responsibility:


Source #2

Source Name:

Source Type:
Other (specify):

Treatment at Source: (prior to tanker or distribution to plant):


Source water distribution to plant:


Source Annual Testing Responsibility:


Source #3

Source Name:

Source Type:
Other (specify):

Treatment at Source: (prior to tanker or distribution to plant):


Source water distribution to plant:


Source Annual Testing Responsibility:


--------------------------------
If you have any additional sources, please provide here.


Brand Names

Sizes of Bottled Water (check all that apply)	8 oz. 0.5 L 16 oz. 1.0 L 1.5 L 2 L 1 Gal	2 Gal 2.5 Gal 3 Gal 5 Gal 18 L 6 Gal

During What Month Do You Submit Samples for Annual Analysis? (check all that apply)
	January	July
	February	August
	March	September
	April	October
	May	November
	June	December

Are you an IBWA Member?

Are you NSF Certified?

In which US States and/or Countries are you bottled water products sold or you plan to distribute within the next six months?

All 50 States (or check states below)
Alabama	Alaska	Arizona
Arkansas	California	Colorado
Connecticut	Delaware	Florida
Georgia	Hawaii	Idaho
Illinois	Indiana	Iowa
Kansas	Kentucky	Louisiana
Maine	Maryland	Massachusetts
Michigan	Minnesota	Mississippi
Missouri	Montana	Nebraska
Nevada	New Hampshire	New Jersey
New Mexico	New York	North Carolina
North Dakota	Ohio	Oklahoma
Oregon	Pennsylvania	Rhode Island
South Carolina	South Dakota	Tennessee
Texas	Utah	Vermont
Virginia	Washington	West Virginia
Wisconsin	Wyoming	Puerto Rico
Canada	Japan	Other (specify)

If you selected other, please specify here >

Please type your question or type of testing you are interested in below.


NOTE: If you have a list of requirements from an agency or regulator, please fax it to us at 440-449-8585 with your cover page.


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