Customer Profile Questionnaire
Customer Service Profile

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