1. What surfaces are you cleaning?

	Polycarbonate, acrylic, and other sensitive plastics
	Filters, membranes, RO or UF systems
	PC boards, wafers, electronic components
	Pipets in syphon washers
	Soft metals: aluminum, copper, brass, other non-ferrous
	Stainless steel, iron, nickel
	Glass, ceramic, porcelain, rubber, fiberglass, plastic
	Other (please describe):

2. What soils are you removing?

	Proteinaceous soils, blood and other body fluids, tissue
	Inorganic soils, scale, salts, metallic complexes, metal oxides, trace metals
	Silicone oils, mold-release agents, buffing compounds, radioisotopes, radioactive contaminants
	Oils, cutting fluids, chemical, solvents, bio-residues, particulates, laboratory soils
	Heavy oils, greases, baked-on residues
	Conductive residues, resins, rosins, solder, fluxes, particulates, salts
	Other (please describe):

3. Where do you use your detergents?

	Household/Janitorial location
	Laboratory
	Central cleaning/service
	Office/Clinic
	Manufacturing process location
	Field cleaning
	Other (please describe):

4. How are you cleaning?

	By hand
	Soak or circulate clean-in-place
	Syphon pipet washer
	Power spray wand
	Ultrasonic (please specify brand):
	(age/yrs)
	Washer/sanitizer (please specify brand):
	(age/yrs)
	Glassware washer (please specify brand):
	(age/yrs)
	Parts washer (please specify brand):
	(age/yrs)
	PC board washer (please specify brand):
	(age/yrs)
	Solvent vapor/soak (please specify brand):
	(age/yrs)
	Other (please describe):

5. If you use cleaning machinery, are you planning to purchase new, upgrade, or replace it in the near future?

	Yes
	No

6. What size detergent do you buy?

	Units (gallons, quarts, 4-lb. boxes, packets)
	Cases of units (9 x 4 lb., 12 x 1 qt., 4 x 1 gal.)
	Medium (25- and 50-lb. boxes, 15-gallon drums)
	Bulk (100 lb., 300 lb., 55-gallon drums) Or, Solujet and Tergajet sample offer
	Other (please describe):

7. Do you now use Alconox, Inc. detergent?

	Yes
	No
	If yes, which detergent (please specify type):
	select type Alcojet Alconox Alcotabs Citrajet Citranox Det-O-Jet Detergent 8 Liquinox Luminox Terg-A-Zyme
	If no, what do you currently use? (please describe):

8. Are you are currently experiencing problems with the cleaner you are using?

9. Any special waste treatment/disposal concerns?

10. Your principal activity:

	Healthcare
	Laboratory
	Environmental & Water Testing
	Electronics
	Pharmaceutical
	Food & Dairy
	Cosmetics
	Metalworking
	Optical
	Nuclear
	Educational Institution
	Medical Device Manufacturing
	Precision Manufacturing (please describe):
	Other (please describe):

11. Estimated annual purchases of high-quality cleaners in US$ (if known): 

12. Please enter your primary job function:

	Administrative Assistant
	Consultant
	Corporate Management
	Engineer
	Healthcare
	Laboratory Manager
	Plant Manager
	Purchasing
	QC/QA Validation
	Safety/Regulatory Compliance
	Sales/Marketing/Distribution
	Scientist/Researcher/Teacher
	Stockroom/Store/Warehouse
	Technician
	Other (please describe):

13. What size/how often do you purchase high-quality cleaners?

	units (single boxes or bottles) - weekly  monthly  yearly
	cases (cases of boxes or bottles) - weekly  monthly  yearly
	med. Sizes (50-100 lb or 5-15 gal drum) - weekly  monthly  yearly
	bulk sizes (300 lb or 55 gal drum) - weekly  monthly  yearly

14. Special complimentary book offer - $39.95 value - The Aqueous Cleaning Handbook

1. I agree to try the samples being sent as a result of this request 2. I agree to let Alconox know the results of my sample trial by completing the sample report card (will be included with samples) 3. I understand that I will be billed $39.95 for the book if I fail to try out and report the results of my trial

Please SEND me the Aqueous Cleaning Handbook. I agree to terms stated above.

If you wish to purchase the book, please order it on our website or call Alconox, Inc. at 1-877-877-2526.