Name:     Title:

Company Name:

Mailing Address:

City:    Province/State:    Postal Code:

Country:

Home Phone:

Work Phone:

Fax Number:

E-Mail Address:

Web Site URL:

Best time to reach me:

BACKGROUND OF COMPANY:

How many years have you been in business?

Corporate officers:

Name:    Title:

Name:    Title:

Name:    Title:

Describe the products or services your company provides.
 

What are your annual sales for the past three years?

What profits has your company made for the past three years?

In what countries do you currently distribute/sell your products?

What percentage of sales are to your principal country?

Is your sales staff: Employees Independent contractors

ADDITIONAL INFORMATION:

Are you able to develop a business with ULTIMA distillers based on renting the units to customers?
Yes No

Do you have sufficient financial resources to provide a rental program? Yes No

If the necessary investment is not available from your own resources, how would the funds be obtained?

Does a rental program fit with the philosophy of your company? Yes No

Recognizing that renting the unit can be very profitable long-term, in your market would you prefer to:
Rent Sell Both rent and sell

Does a rental program fit with the business practices in your country? Yes No

Would you prefer to sell the units outright with a service contract? Yes No

Are you interested in: Local ULTIMA License Master ULTIMA License for the entire country No preference

Is your company or any of its subsidiaries in the following business? Water Treatment Products Bottled Water Supplier to water treatment or bottled water company

Is your company prepared to form a separate ULTIMA branch or division to focus entirely on the ULTIMA opportunity? Yes No

Will you devote full-time to this business? Yes No

Do you plan to have a partner? Yes No

Do you plan to have investors? Yes No

If so, will the partner be active?* Yes No
*If you plan to have an active partner, please have your partner submit a Confidential Profile as well.

Where and when did you first learn about the ULTIMA 888?

Have you seen an existing ULTIMA 888 Franchise location? Yes No
If so, Where?

Where is your choice of market?

Entire Country:

Province/State/Region:

Local Area/City:

By what date do you wish to open your Pure Water ULTIMA operation?

Please state generally the reasons for your interest in the Pure Water ULTIMA Franchise?


The information furnished in this form is not binding and does not obligate either you or Pure & Secure, LLC. in any way. The purpose is to provide our company with necessary information to evaluate you as an applicant. The answers will be held in strict confidence, and we will assume that they are factually correct. We will not, however, attempt to verify this information without notifying you first.