Customer Order Form


Thank you for choosing Pure Water Connection. Please complete the customer information section and select which products you are interested in. Once you have completed the order form, one of our customer representatives will get in touch with you to provide an estimate and complete your order.

Customer Information

To reorder water click the banner above.

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I am a current customer
Name *
Address
City
Province
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Phone Number *
Email Address *
Best time to call

2 Stage - Sediment/Carbon Filter System
Use: Residential Commercial
Water Source: Well water City water
Dispensing Method: Water Cooler Faucet at Sink Faucet at Sink with under counter water chiller
I am interested in: Purchase Rental

4 Stage Reverse Osmosis System
Use: Residential Commercial
Water Source: Well water City water
Dispensing Method: Water Cooler Faucet at Sink Faucet at Sink with under counter water chiller
I am interested in: Purchase Rental

pH Balance 4 Stage Reverse Osmosis System
Use: Residential Commercial
Water Source: Well water City water
Dispensing Method: Water Cooler Faucet at Sink Faucet at Sink with under counter water chiller
I am interested in: Purchase Rental

5 Stage - PureValue Reverse Osmosis System
Use: Residential Commercial
Water Source: Well water City water
Dispensing Method: Water Cooler Faucet at Sink Faucet at Sink with under counter water chiller
I am interested in: Purchase Rental

6 Stage Re-Mineralizing Reverse Osmosis System
Use: Residential Commercial
Water Source: Well water City water
Dispensing Method: Water Cooler Faucet at Sink Faucet at Sink with under counter water chiller
I am interested in: Purchase Rental

Mini Rack Systems
I am interested in: Purchase Rental

Iceberg Undersink Water Cooler (Room Temp. and Cold Model)
I am interested in: Purchase Rental

Assorted Filters
We carry the most popular types of replacement filters for residential, commercial and industrial systems. Replacement filters available for the following: in-line gac, sediment, carbon block, gac, reverse osmosis membranes, mineral boosters and ph boosters. A wide array of sizes for the smaller residential system to a commercial system big blue style housing.
Please indicate the type /size and quantity you are interested
Home Water Analysis
Use: Residential Commercial
Water Source: Well water City water
Would you like a FREE water Analysis and Consultation? Yes
Well Water Problem check list (check all that apply):
Iron Problems Hardness Manganese Turbidity Hydrogen Sulfide
Methane Gas Nitrates E-Coli Coliform Tannin Not Sure

Liquid Chlorine System - Hydrogen Peroxide System
I am interested in: Purchase

Potassium Permanganate System
I am interested in: Purchase

Water Softeners
I am interested in: Purchase

Multi Media Tannin (colour) Removal System
I am interested in: Purchase

Multi Media Filters
I am interested in: Purchase

Distillation
I am interested in: Purchase

Activated Carbon Filtration
I am interested in: Purchase

Ultraviolet Lights
I am interested in: Purchase

Miscellaneous Accessories
We carry a variety of miscellaneous accessories for our water conditioning systems. (ex. Iron out, Res Up, Hydrogen Peroxide, Activated Carbon, Liquid Chlorine, Pellet Chlorine)
Please indicate the type /size and quantity of filters you are interested
Reverse Osmosis
Use: Residential Commercial
# of People: 0-10 11-30 31-50 more than 50
Are you currently using bottled water? Yes
If yes how many bottles are you using per month?
0-10 11-20 21-30 31-40 more than 40
BPA Free: Yes
I am interested in: 18.9L 11.35L

Steam Distilled
Use: Residential Commercial
# of People: 0-10 11-30 31-50 more than 50
Are you currently using bottled water? Yes
If yes how many bottles are you using per month?
0-10 11-20 21-30 31-40 more than 40
BPA Free: Yes
I am interested in: 18.9L 11.35L

Monashee Spring Water
Use: Residential Commercial
# of People: 0-10 11-30 31-50 more than 50
Are you currently using bottled water? Yes
If yes how many bottles are you using per month?
0-10 11-20 21-30 31-40 more than 40
BPA Free: Yes (only available in 18.9L )
I am interested in: 18.9L 11.35L 4L 500ml
Avalanche Crystal Mountain Coolers
Model: Cold – $300.60 Hot & Cold – $345.60
I am interested in: Purchase Rental

K2 Bottled Water Cooler
Use: Residential Commercial
Model: Hot & Cold w/ cup disp. – $381.80
I am interested in: Purchase

Glacier Crystal Mountain Coolers
Use: Residential Commercial
Model: Room Temp. and Cold – $297.00 Hot & Cold – $334.80
Colour: White Black
I am interested in: Purchase Rental

Storm Bottom Load
Model: Hot & Cold – $382.50

Aspen
Model: Room Temp. & Cold – $228.60 Hot & Cold – $253.80

Nordic Stainless Cabinet
Model: Room Temp. and Cold – $279.00 Hot & Cold – $297.00
Ceramic Dispenser
Model
Sunflower – $59.70
Gold Band – $59.70
Green Ivy – $59.70
Blue Stripe – $59.70
Green Stripe – $59.70
Plain – $59.70

Stands
Model
Wood Counter Stand – $33.15
Wood Floor Stand – $50.75

H2OK Cleaning Kit – $10.00

Hand Pump – $30.25

Cup Dispenser – $18.00

Paper Cups
Sleeve (200 per sleeve) – $6.05
Case (5000 per case) – $151.00

Plastic Cups
Sleeve (100 per sleeve) – $7.40
Case (2500 per case) – $185.00

Stainless Steel Bottle Cradle – $23.80

Crown Neck Valve - $23.80

Aqua-Stakka – $14.05

Bottle Buddy
$31.25 ea.
$375.00/Case of 12

Bottle Storage Stand
3 Bottle Stand – $100.80 ea.
6 Bottle Stand – $142.80

Easy Load Reusable No-Splash Cap – $13.75

Dry guard – $40.00

Electric Water Pump-Bottle Water Dispensing System – $315.70

CQ-1000 Dechlorinating Shower Filter
Shower Filter – $92.05
Replacement Cartridge – $60.20

The Crystal Ball Bath Dechlorinator
Crystal Ball Bath Dechlorinator – $97.10
Replacement Cartridge – $69.10

Battery Powered Pump – $43.30

6 Bottle Wire Rack – $95.00
Private Labeled Water (500ml bottles)
Order Frequency: One time Recurring
Label: Already have one Need one designed
# of Bottles: Minimum order 240 bottles (10 cases)
All orders must be complete cases (24 bottles / case)
Coffee Delivery
Whole Bean K-Cup

All Prices are Subject to Change without notice.
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Products
Bottled Water
Water Coolers
Accessories
Filtration
Water Conditioning
Private Labeled Water

Edmonton Delivery
& Pick Up Locations
Edmonton & Area
Delivery Schedules
Pick Up Locations
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Order Form
Pure Water Connection
10739 – 180 Street, Edmonton, AB T5S 1G6
P: (780) 413-6547 F: (780) 413-6501
E: accounts@purewaterconnection.ca
Hours
Monday to Friday: 9AM – 5PM
Saturday: 10AM – 2PM
* Closed Holiday Weekends