Customer Interest Survey

Tell us how you'd like to work with Fluidseal. This helps us set up your account, contacts, and the products and materials you care about.

Your responses are sent to our team and saved to our system. Fields marked * are required.

Account & Submission

Date

Filled Out By *

Account Name *

City

Industry Group

Industry

Sales Contact

First Name

Last Name

Job Title

Phone #

Preferred Method of Contact

Office Phone Mobile Phone Email

Administration / Accounts Payable Contact

First Name

Last Name

Invoices Sent Via

Phone #

Preferred Method of Contact

Office Phone Mobile Phone Email

Payment Option(s)

Cash Credit Debit Cheque Direct Deposit E-Transfer

Services of Interest

For each service, mark whether you'd require it and whether you're currently using it (with any supplier).

Comments — Services

Packaging of Interest

Comments — Packaging

Subscriptions — Catalogues

Choose how you'd like to receive each catalogue.

Subscriptions — Technical Updates

Subscriptions — Flyers

Subscriptions — Charts

Subscriptions — Posters

Promotional Items

Comments — Promotional Items

Anything Else?

General comments / special requests

17309 - 107th Ave
Edmonton, AB T5S 1E5
T: 780.414.1871 · F: 780.487.5419
E: fluidsealab@sealsonline.com

Bay #6, 3815 - 61st Ave SE
Calgary, AB T2C 1V5
T: 403.279.1871 · F: 403.279.1821
E: fluidsealcg@sealsonline.com