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Potable Aqua Sign Up Information

Last Updated:

11/3/2019

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Yes

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Email Address

Your Address

Home Address, City, State, Country, Postcode

Post-Registration Data

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This site did not show evidence of storing passwords in plaintext.

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This site does verify your email address.

Membership Emails

Below is a sample of the emails you can expect to receive when signed up to Potable Aqua.

Potable Aqua PURE Warranty Inf...

Thank you for submitting your Potable Aqua PURE Electrolytic Water Purifier device warranty registration!� Upon receipt and verification of your proof of purchase, you will receive an email with a warranty registration number to complete your warranty registration.� Please contact customer service at�info@pharmacalway.com�or by phone at 800-558-6614 with questions or concerns.

Your submission is below for your records.

Name
�	Jon Jon
Company Name (if applicable)
�	Jon
Address
�	208 Langham Road 192 Langham Road London, Jon N15 3NB Lebanon Map It
Email
�	@
Phone
�	(079) 536-9303

What is your primary intended use for your PURE device? (choose al that apply)
�	Emergency Preparedness

Where did you learn about Potable Aqua PURE?
�	Saw an online ad
On what website did you see our online ad?
�	Jon

Where did you purchase your PURE device?
�	Jon
Date of Purchase?
�	11/02/2019
*Proof of Purchase (must choose one)**
�	I will fax a copy of my purchase receipt to Wisconsin Pharamcal Company (Fax number: (262) 677-9006)
Lot Code
�	1444

Raw Data Registration Structure Registration Form Text

Registration

Name*

Home address

City

State

Country

Postcode

Country

Phone*

What is your primary intended use for your PURE device? (choose al that apply)

Emergency Preparedness

International Travel

Camping / Backpacking

Where did you learn about Potable Aqua PURE?

From a Friend

Saw an online ad

Saw it on shelf at the store

Saw print ad

Proof of Purchase* (must choose one)*

I will upload an image of my purchase receipt now

I will fax a copy of my purchase receipt to Wisconsin Pharamcal Company (Fax number: (262) 677-9006)

Data Name	Data Type	Options
Name*	Text Box
Email	Text Box
Home address	Text Box
City	Text Box
State	Text Box
Country	Text Box
Postcode	Text Box
Country	dropdown
Phone*	tel
	checklist	What is your primary intended use for your PURE device? (choose al that apply)
	checklist	Emergency Preparedness
	checklist	International Travel
	checklist	Camping / Backpacking
	checklist	Where did you learn about Potable Aqua PURE?
	checklist	From a Friend
	checklist	Saw an online ad
	checklist	Saw it on shelf at the store
	checklist	Saw print ad
	option	Proof of Purchase* (must choose one)*
	option	I will upload an image of my purchase receipt now
	option	I will fax a copy of my purchase receipt to Wisconsin Pharamcal Company (Fax number: (262) 677-9006)
	file