Institutional Site Survey Form
This form is designed to be used for each location the client might have. (Limited to 4 locations per form)
Your Name
*
First Name
Last Name
Your Email
*
example@example.com
Distributor Name or Direct?
*
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Next
Client Details
Client Venue Name
*
New Client or Existing Client
*
New Client
Existing Client
Client Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client Primary Contact Name
*
Name
Position
Client Contact Email
*
This is where service reports will be emailed to, you can enter more than one.
Client Contact Number
*
Primary Contact is Available
Rows
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
AM
PM
Service Call Time
Delivery Options
*
Please Select
Hand Unload
Tailgate Unload
Forklift Unload (Forklift onsite)
Installation Request date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
This is a request date only. All Installation are scheduled by the Installation Service Manager.
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Location - 1 Service Details
Location Name
*
Call Frequency
*
Please Select
2 Weeks (PLATINUM)
4 Weeks (GOLD)
8 Weeks (SILVER)
16 Weeks (BRONZE)
Rental Only ( $32.5.0 month )
Glasswasher ( $20.00/month )
NA
Dishwasher
*
Yes
No
Is An Electrician Required For Install
*
Yes
No
Dishwasher Make
Dishwasher Model
Warewash Dispenser Option
Seko Waredose 35
Brightwell Quantura 200 HD
No - Internal Pump
Other
Warewash Chemical Required
Rows
Product Name
Product Size
Auto Dishwash Detergent
Rinse Aid
Glasswasher
*
Yes
No
Glasswasher Pump Options
No - Internal Pump
Detergent ( xe-gwd )
Rinse Aid ( xe-npr0301 )
Other
Glasswasher Make
Glasswasher Model
Glass Wash Chemical Required
Rows
Product Name
Product Size
Auto Glass Wash Detergent
Rinse Aid (if applicable)
Mixing Station Required
*
Yes - Water Fed (Pro Max)
Yes - Waterless (Eco Shot)
No
Pro Max - Mixing Station Options
Rows
1
2
0
1 Product Bucket
4 Product Bottle
4 Product Bucket
3 Product Bottle & 1 Product Bucket
Products for Faceplate
Rows
Product 1
Product 2
Product 3
Product 4
Faceplate 1
Faceplate 2
Faceplate 3
Faceplate 4
Eco Shot - Mixing Station Options
Rows
1
2
3
4
5
0
Smartpump Bottle Fill
Smartpump Bucket Fill
Products for Faceplate
Rows
Product 1
Product 2
Product 3
Product 4
Product 5
Product Stickers
Sink Pump Options
Rows
1
2
0
Hydro Pump 616
Pelican Pump
Smartpump Sink Fill
Manual Dishwashing Chemical Required
Rows
Product Name
Product Size
Detergent
Racks Options
Rows
1
2
3
4
5
0
Rack 5L x 1 (Narrow)
Rack 5L x 1 (Wide)
Rack 5L x 2 (Narrow)
Rack 5L x 2 (Wide)
Wall Charts
Rows
1
2
3
4
5
0
Dishwashing Procedure
Guidelines For Handling Chemicals
Proper Hand-Washing and Sanitising
SDS and Product Chart
Is HandCare Required?
Yes
No
Number of Dispensers?
Product Required
Rows
Yes
No
Hand & Body Wash
Hand & Body Foam
Antibac Wash (kitchen)
Antibac Foam (kitchen)
Antibac Hand & Body Wash
Antibac Hand & Body Foam
Sani Gel (Alcohol)
Sani Hands (Alcohol free)
Dispenser Install Surface
Please Select
Mirror / Glass
Plasterboard
Concret
Tiled
Fibro / Cement
Steel
Wood
What surface is the HandCare dispenser being installed on?
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Location comments
Do you want to add another location?
Yes
No
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Next
Location - 2 Service Details
Location Name
*
Call Frequency
*
Please Select
2 Weeks (PLATINUM)
4 Weeks (GOLD)
8 Weeks (SILVER)
16 Weeks (BRONZE)
Rental Only ( $32.5.0 month )
Glasswasher ( $20.00/month )
NA
Dishwasher
*
Yes
No
Is An Electrician Required For Install
*
Yes
No
Dishwasher Make
Dishwasher Model
Warewash Dispenser Option
Seko Waredose 35
Brightwell Quantura 200 HD
No - Internal Pump
Other
Warewash Chemical Required
Rows
Product Name
Product Size
Auto Dishwash Detergent
Rinse Aid
Glasswasher
*
Yes
No
Glasswasher Pump Options
No - Internal Pump
Detergent ( xe-gwd )
Rinse Aid ( xe-npr0301 )
Other
Glasswasher Make
Glasswasher Model
Glass Wash Chemical Required
Rows
Product Name
Product Size
Auto Glass Wash Detergent
Rinse Aid (if applicable)
Mixing Station Required
*
Yes - Water Fed (Pro Max)
Yes - Waterless (Eco Shot)
No
Pro Max - Mixing Station Options
Rows
1
2
0
1 Product Bucket
4 Product Bottle
4 Product Bucket
3 Product Bottle & 1 Product Bucket
Products for Faceplate
Rows
Product 1
Product 2
Product 3
Product 4
Faceplate 1
Faceplate 2
Faceplate 3
Faceplate 4
Eco Shot - Mixing Station Options
Rows
1
2
3
4
5
0
Smartpump Bottle Fill
Smartpump Bucket Fill
Products for Faceplate
Rows
Product 1
Product 2
Product 3
Product 4
Product 5
Product Stickers
Sink Pump Options
Rows
1
2
0
Hydro Pump 616
Pelican Pump
Smartpump Sink Fill
Manual Dishwashing Chemical Required
Rows
Product Name
Product Size
Detergent
Racks Options
Rows
1
2
3
4
5
0
Rack 5L x 1 (Narrow)
Rack 5L x 1 (Wide)
Rack 5L x 2 (Narrow)
Rack 5L x 2 (Wide)
Wall Charts
Rows
1
2
3
4
5
0
Dishwashing Procedure
Guidelines For Handling Chemicals
Proper Hand-Washing and Sanitising
SDS and Product Chart
Is HandCare Required?
Yes
No
Number of Dispensers?
Product Required
Rows
Yes
No
Hand & Body Wash
Hand & Body Foam
Antibac Wash (kitchen)
Antibac Foam (kitchen)
Antibac Hand & Body Wash
Antibac Hand & Body Foam
Sani Gel (Alcohol)
Sani Hands (Alcohol free)
Dispenser Install Surface
Please Select
Mirror / Glass
Plasterboard
Concret
Tiled
Fibro / Cement
Steel
Wood
What surface is the HandCare dispenser being installed on?
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Location comments
Do you want to add another location?
Yes
No
Back
Next
Location - 3 Service Details
Location Name
*
Call Frequency
*
Please Select
2 Weeks (PLATINUM)
4 Weeks (GOLD)
8 Weeks (SILVER)
16 Weeks (BRONZE)
Rental Only ( $32.5.0 month )
Glasswasher ( $20.00/month )
NA
Dishwasher
*
Yes
No
Is An Electrician Required For Install
*
Yes
No
Dishwasher Make
Dishwasher Model
Warewash Dispenser Option
Seko Waredose 35
Brightwell Quantura 200 HD
No - Internal Pump
Other
Warewash Chemical Required
Rows
Product Name
Product Size
Auto Dishwash Detergent
Rinse Aid
Glasswasher
*
Yes
No
Glasswasher Pump Options
No - Internal Pump
Detergent ( xe-gwd )
Rinse Aid ( xe-npr0301 )
Other
Glasswasher Make
Glasswasher Model
Glass Wash Chemical Required
Rows
Product Name
Product Size
Auto Glass Wash Detergent
Rinse Aid (if applicable)
Mixing Station Required
*
Yes - Water Fed (Pro Max)
Yes - Waterless (Eco Shot)
No
Pro Max - Mixing Station Options
Rows
1
2
0
1 Product Bucket
4 Product Bottle
4 Product Bucket
3 Product Bottle & 1 Product Bucket
Products for Faceplate
Rows
Product 1
Product 2
Product 3
Product 4
Faceplate 1
Faceplate 2
Faceplate 3
Faceplate 4
Eco Shot - Mixing Station Options
Rows
1
2
3
4
5
0
Smartpump Bottle Fill
Smartpump Bucket Fill
Products for Faceplate
Rows
Product 1
Product 2
Product 3
Product 4
Product 5
Product Stickers
Sink Pump Options
Rows
1
2
0
Hydro Pump 616
Pelican Pump
Smartpump Sink Fill
Manual Dishwashing Chemical Required
Rows
Product Name
Product Size
Detergent
Racks Options
Rows
1
2
3
4
5
0
Rack 5L x 1 (Narrow)
Rack 5L x 1 (Wide)
Rack 5L x 2 (Narrow)
Rack 5L x 2 (Wide)
Wall Charts
Rows
1
2
3
4
5
0
Dishwashing Procedure
Guidelines For Handling Chemicals
Proper Hand-Washing and Sanitising
SDS and Product Chart
Is HandCare Required?
Yes
No
Number of Dispensers?
Product Required
Rows
Yes
No
Hand & Body Wash
Hand & Body Foam
Antibac Wash (kitchen)
Antibac Foam (kitchen)
Antibac Hand & Body Wash
Antibac Hand & Body Foam
Sani Gel (Alcohol)
Sani Hands (Alcohol free)
Dispenser Install Surface
Please Select
Mirror / Glass
Plasterboard
Concret
Tiled
Fibro / Cement
Steel
Wood
What surface is the HandCare dispenser being installed on?
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Location comments
Do you want to add another location?
Yes
No
Back
Next
Location - 4 Service Details
Location Name
*
Call Frequency
*
Please Select
2 Weeks (PLATINUM)
4 Weeks (GOLD)
8 Weeks (SILVER)
16 Weeks (BRONZE)
Rental Only ( $32.5.0 month )
Glasswasher ( $20.00/month )
NA
Dishwasher
*
Yes
No
Is An Electrician Required For Install
*
Yes
No
Dishwasher Make
Dishwasher Model
Warewash Dispenser Option
Seko Waredose 35
Brightwell Quantura 200 HD
No - Internal Pump
Other
Warewash Chemical Required
Rows
Product Name
Product Size
Auto Dishwash Detergent
Rinse Aid
Glasswasher
*
Yes
No
Glasswasher Pump Options
No - Internal Pump
Detergent ( xe-gwd )
Rinse Aid ( xe-npr0301 )
Other
Glasswasher Make
Glasswasher Model
Glass Wash Chemical Required
Rows
Product Name
Product Size
Auto Glass Wash Detergent
Rinse Aid (if applicable)
Mixing Station Required
*
Yes - Water Fed (Pro Max)
Yes - Waterless (Eco Shot)
No
Pro Max - Mixing Station Options
Rows
1
2
0
1 Product Bucket
4 Product Bottle
4 Product Bucket
3 Product Bottle & 1 Product Bucket
Products for Faceplate
Rows
Product 1
Product 2
Product 3
Product 4
Faceplate 1
Faceplate 2
Faceplate 3
Faceplate 4
Eco Shot - Mixing Station Options
Rows
1
2
3
4
5
0
Smartpump Bottle Fill
Smartpump Bucket Fill
Products for Faceplate
Rows
Product 1
Product 2
Product 3
Product 4
Product 5
Product Stickers
Sink Pump Options
Rows
1
2
0
Hydro Pump 616
Pelican Pump
Smartpump Sink Fill
Manual Dishwashing Chemical Required
Rows
Product Name
Product Size
Detergent
Racks Options
Rows
1
2
3
4
5
0
Rack 5L x 1 (Narrow)
Rack 5L x 1 (Wide)
Rack 5L x 2 (Narrow)
Rack 5L x 2 (Wide)
Wall Charts
Rows
1
2
3
4
5
0
Dishwashing Procedure
Guidelines For Handling Chemicals
Proper Hand-Washing and Sanitising
SDS and Product Chart
Is HandCare Required?
Yes
No
Number of Dispensers?
Product Required
Rows
Yes
No
Hand & Body Wash
Hand & Body Foam
Antibac Wash (kitchen)
Antibac Foam (kitchen)
Antibac Hand & Body Wash
Antibac Hand & Body Foam
Sani Gel (Alcohol)
Sani Hands (Alcohol free)
Dispenser Install Surface
Please Select
Mirror / Glass
Plasterboard
Concret
Tiled
Fibro / Cement
Steel
Wood
What surface is the HandCare dispenser being installed on?
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Location comments
Back
Next
Additional Products required for site install
Rows
Product Name
Product Size
Product 1
Product 2
Product 3
Product 4
Product 5
Comments
Submit
Should be Empty: