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Cleaning Product Questionnaire
Name
*
First
Last
Email
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Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
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Austria
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Bouvet Island
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Cayman Islands
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Cook Islands
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Korea, Republic of
Kuwait
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Libya
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Malaysia
Maldives
Mali
Malta
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Mauritius
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Panama
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Pitcairn
Poland
Portugal
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Qatar
Romania
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Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
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Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
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Sierra Leone
Singapore
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Slovakia
Slovenia
Solomon Islands
Somalia
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South Georgia and the South Sandwich Islands
South Sudan
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Sudan
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Sweden
Switzerland
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Taiwan
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Tanzania, the United Republic of
Thailand
Timor-Leste
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Tonga
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Türkiye
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Uganda
Ukraine
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United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Item(s) To Be Cleaned
Surface Material To Be Cleaned (Check All That Apply)
Steel
Cast Iron
Brass
Copper
Bronze
Aluminum
Zinc Die Cast
Galvanized
Stainless
Nickel
Chrome
Plastic
Other
Soils To Be Cleaned
Types of Cleaning Equipment
Belt Washer
Rotary Drum
Rotary Basket
Vertical Agitation
Conveyor Spray
Ultrasonic Cabinet
(Spray Immersion Ultrasonic)
Other
Stage 1
Stage 1 Function
Stage 1 Time
Stage 1 Temperature
Stage 1 Concentration
Stage 2
Stage 2 Function
Stage 2 Time
Stage 2 Temperature
Stage 2 Concentration
Stage 3
Stage 3 Function
Stage 3 Time
Stage 3 Temperature
Stage 3 Concentration
Stage 4
Stage 4 Function
Stage 4 Time
Stage 4 Temperature
Stage 4 Concentration
Stage 5
Stage 5 Function
Stage 5 Time
Stage 5 Temperature
Stage 5 Concentration
Products Presently Used
Product
Usage
Price
Volume
Product
Usage
Price
Volume
Product
Usage
Price
Volume
Problems or Desired Improvements With Presently Used Products
Cleaner Restrictions
pH
Temperature
Exposure
Ingredients (phosphates, chelators etc)
Operation Before Cleaning
Operation After Cleaning
Is Corrosion Inhibition Necessary?
Yes
No
For How Long?
Sample size necessary for evaluation
Comments
Do you currently have a distributor?
Yes
No
Who is your distributor?
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