Hydro-Air Quote Request


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Hydro-Air™ Esti-Mate® Request Form

Step 1: Fill out the information in this section as completely as possible:

*Your Name:

Design Completed?
YesNo

If Yes Bin Number:
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*Company:

*Project Name:

Owner (s):

*Address:

*Project Address (City):

Architect:

*City:

*State: Zip Code:

Engineer:

*Phone:

*Cell Phone:

General:

*Fax:

*E-Mail:

*Required Fields

Step 2: Fill out equipment selection if known:

Step 3: You may submit a wholesaler in your area to receive the quote:

Contact Name:

Multiple Branches?YesNo

Main Office? YesNo

Company:

Number Of Branches:

Purchasing Contact Name:

Address:

Type: PlumbingHVACOther

Other:

City:

State: Zip Code:

Website:

Phone:

Fax:

E-Mail:

Note:Please print and fax this request directly to your Wholesaler. If you do not have a Wholesaler, please complete step 3 above. You may submit this form directly to Bio-Radiant Energy via E-Mail by clicking on the 'Submit' button below. Wholesalers and other companies submitted are verified to determine if they qualify as an authorized Wholesaler. Some companies do not fit our profile and do not qualify. If this is the case we will contact you and direct you to the nearest Authorized Wholesaler.

Bio-Radiant Energy, Inc. is authorized to send a quote for this job and/or a quote for the above list of equipment, to the nearest Primary Wholesaler. I understand that Bio-Radiant Energy quotes prices only through Authorized Wholesalers and will not provide me with direct quotations. By Sumitting this document we agree to the Terms of Use as indicated below.

PLEASE FAX OR MAIL TO THE FOLLOWING ADDRESS Operated Exclusively By: Bio-Radiant Energy, Inc. 16928 Woodinville-Redmond Rd. N.E. Woodinville, WA 98072 USA 425•487•6272 Toll Free800•598•1019 FAX425•487•0084 www.popularhydronics.com

Terms of Use: No guarantee is expressed or implied that any Wholesaler will be authorized, obligated or even allowed to sell to you without proper account status. Use of this system does not constitute a guarantee that you will receive a quotation. The Wholesalers obligation to provide you with a quote rests entirely with the Wholesaler. All information is strictly confidential and will not be revealed to any third party firms or individuals without proper authorization. Bio-Radiant Energy, Inc. reserves the right to refuse service to anyone, for any reason, including, but not limited to, abuse, mis-representation, or any illegal activities. For questions about this Esti-Mate® Request please direct your inquiries to your primary Wholesaler or contact Bio-Radiant Energy, Inc.