(If you have your dealer ID number, you do not
need to fill in the contact information below)
Dealer Name
*
Contact Name
*
Phone Number
*
Fax Number
*
Email Address
*
Ship to Zip Code
*
2. Product Selection:
Please select product(s) from the list below.
Multiple selections can be made. Please call Customer Service
at 1-866-663-1982 if you need immediate attention.
Adult Height Portable
Sinks
PremierTM Adult with ABS Single
Basin and Top
QTY
PremierTM Adult with Single
Stainless Steel Basin
QTY
PremierTM Adult with Double
Stainless Steel Basin
QTY
PremierTM Adult with Triple
Stainless Steel Basin
QTY
Eye Wash Station with ABS Single Basin
and Top
QTY
Preschool Height
Portable Sinks
Lil' PremierTM Preschool ABS Single
Basin
QTY
Lil' PremierTM Single Stainless Steel
Basin
QTY
Diaper Changing Station
Portable Sink
Kiddie StationTM with ABS Single Basin
QTY
Kiddie StationTM with Single Stainless
Steel Basin
QTY
Kiddie StepTM Slip-resistant toddler
step
QTY
Four Basin Station
Portable Sink
DeluxTM with 2, Double Stainless
Steel Basins
QTY
Lil' DeluxTM with 2, Double Stainless
Steel Basins
QTY
Steramine 200 PPM
Quaternary Sanitizer
Express Pack with 10- 1 oz packets
QTY
Master Pack with 10- Express Packs
QTY
Sanitizer Starter Kit
QTY
Accessories for
Portable Sinks
EZ Flow Water Sensor
QTY
EZ Fill-N-Roll Tank Dolly and Fill
Tube Kit
QTY
EZ-Fill 4.5' Refill Tube
QTY
5-Gallon Water Tank
QTY
6-Gallon Water Tank
QTY
By submitting this form you
are agreeing that you are an authorized dealer. We will
contact you with the quotation within one hour during
regular hours of operation. Please call 1-866-663-1982
if you need immediate attention. I AGREE
