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Home Delivery CONTACT INFORMATION Last Name* First Name* Address* City, State & Zip* AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA DC WV WI WY AB BC MB NB NL NT NS NU ON PE QC SK YT Home Phone Number* Work Phone Number Other Phone Number E-mail Address* CHOOSE A PLAN Family Savings Plan Flex Plan (Click plan name to see an overview) FAMILY SAVINGS PLAN Click here to view coolers 3 Five gallon bottles of spring water & cooler $27.95/mo. 4 Five gallon bottles of spring water & cooler $29.95/mo. 5 Five gallon bottles of spring water & cooler $34.95/mo. 6 Five gallon bottles of spring water & cooler $39.95/mo. SELECT COOLER TYPE HOT / COLD COOK / COLD SELECT COOLER COLOR WHITE BLACK FLEX PLAN Five gallon bottle of spring water @ $6.99 each Three gallon bottle of spring water @ $5.79 each Five gallon bottle of distilled / purified water @ $7.49 each I ALREADY OWN A WATER DISPENSER - NONE NEEDED COOLER RENTAL (Click here to view coolers) SELECT COOLER TYPE HOT / COLD @ $14.00 / month COOK / COLD @ $11.00 / month SELECT COOLER COLOR WHITE BLACK COOLER PURCHASE (Click here to view coolers) SELECT COOLER MODEL STANDARD WHITE BLACK & STAINLESS STEEL PREMIUM NEVADA -- CHOOSE COLOR -- Silver Blue Burgundy Orange Dark Grey Cream CROCK CROCK & COUNTER STAND CROCK & FLOOR STAND SELECT COOLER TYPE HOT / COLD COOK / COLD COOK ONLY (Crock only) CASE DELIVERY Add Case Delivery with my 5 or 3 gallon bottles 1 Gallon Spring Water (6 pack) 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 1 Gallon Distilled/Purified (6 pack) 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 24 oz. Spring Water (24 pack) 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 HOW DID YOU LEARN ABOUT US? Contacted by sales representative Internet Search Phone Book Referral Saw Truck Chamber of Commerce Other Comments:
Family Savings Plan Flex Plan (Click plan name to see an overview)
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