Customer Service Profile

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D.W. Davies & Co., Inc. is committed to supply to the specialty chemical marketplace the highest quality products and technical service available. So that we may best suit your needs as our customer, please take the time to complete the customer service questionnaire below. The information you supply us will be kept strictly confidential.

Company/Organization Name
Address Line #1
Address Line #2
City		State		Zip
Primary Contact Name		Job Title
Phone		Fax
Email
Website Address (url)

Please describe the primary nature of your business or organization:

We commonly use the following types of products: (please check all that apply)

	Aerosol Products		Industrial Chemicals
	Aircraft Products		Institutional Products
	Automotive Products		Insecticides
	Concrete Maintenance Products		Janitorial Products
	DC-99 Cleaner -Degreaser-Wax Stripper		Lubricants, Greases & Oils
	Enzymes		Sanitation Products
	Equipment		Swim Pool Products
	Food Service Products		Transportation Products
	Ground Control Products		Water Treatment Chemicals
	Housekeeping Products		Other (specify below)

We prefer to receive Davies products updates and announcements by: (please check all that apply)
	Mail		E-mail		Fax		Phone

Thanks for completing our questionnaire! Please fax or mail to: FAX 262-637-3933

D.W. DAVIES & CO., INC. 3200 PHILLIPS AVENUE  RACINE, WI. 53403

QUESTIONS? Call us at (262) 637-6133 or 1-800-888-6133

WEBSITE: http://www.dwdavies.com EMAIL: service@dwdavies.com

Date Received	Distributor	Sales Representative	Account#	Region