Customer order form

Agua Katya Customer Form

Place your water order with this form *required fields
Name/nombre*

First NameLast Name
Phone Number/numero*
Please enter a valid phone number.
Address/domicillo*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date*

DayMonthYear
Date

Product list

RO Water

30.00MXN

RO Water	Quantity
11 Liters
19 Liters

Item subtotal:0.00MXN

Alkaline Water

“Hydration with an extra boost.” Balanced at a higher pH, our Alkaline water is smooth-tasting and refreshing.

35.00MXN

Alkaline Water	Quantity	Price
11 Liters		35.00MXN
19 Liters		45.00MXN

Item subtotal:0.00MXN

Standard Deposit bottle 19L/11L - Alkaline or RO

Use this option if you are a first time customer and you have no bottles to trade in. The price is for each bottle not per order. This deposit is refundable if you decide to cancel the service return the bottle with the receipt.

100.00MXN

	Quantity
11 Liters
19 Liters

Item subtotal:0.00MXN

Rechargeable Garrafon Pump

175.00MXN

	Quantity
garrafon pump

Item subtotal:0.00MXN

Mama Cleo's Donation Bottle

Please help us give some support to this great program . For every one you buy Agua Katya donates one for free. For more information please visit this link. https://www.facebook.com/people/Mama-Cleos-Boys-Home/100063700712798/

30.00MXN Quantity
Item subtotal:0.00MXN

RO Prepaid Packages

Prepaid Packages — Simple, Smart, and Affordable Save money and lock in convenience when you prepay for bottles: 1st order: 7% OFF 2nd order: 5% OFF Free pump with 10 and 20 packages Choose RO or Alkaline below to get started

FreeMXN Quantity
Item subtotal:0.00MXN

Alkaline Prepaid Packages

FreeMXN Quantity

Total

0.00MXN

Delivery Frequency (how often you want deliveries)
Delivery Frequency (Specify)
Special instructions
Should be Empty:

Agua Katya Customer Form