Product Request Form  -   Fields marked with an * are required.

First Name*    Middle Initial      Last Name* 
Street Address*
City*    State/Province* 
Country     Zip/Postal Code* 
Telephone Number  -   -     Email*  
What is it?*
(as detailed as possible, include a sketch or diagram)
Where does it apply?*
(where in your system or company will it be used, such as distribution piping, maintenance, treatment plant, etc.)
Who?*
(who will use this item or who will approve its purchase)
Why is it worth exploring?*
(potential for cost/time savings, efficiency improvements, better safety, easier maintenance, nothing similar available, current items inferior, etc.)
What is the estimated annual usage?*
When will it be needed?*
Sources for more information...

Mueller Company Water Products Division Return completed form by mail or fax to:
Mueller Company
500 W. Eldorado St.
PO Box 671
Decatur IL 62522
FAX: (217) 425-7537