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Order Request Form
Step
1
of
2
50%
Name
*
First
Last
Phone
*
Email
*
Order Date
*
MM slash DD slash YYYY
Address Type
*
Residential
Commercial
Requested Delivery Date
*
MM slash DD slash YYYY
Requested Delivery Time
*
Please Select a Time
8:00AM
8:30AM
9:00AM
9:30AM
10:00AM
10:30AM
11:00AM
11:30AM
12:00PM (Noon)
12:30PM
1:00PM
1:30PM
2:00PM
2:30PM
3:00PM
3:30PM
4:00PM
4:30PM
5:00PM
5:30PM
6:00PM
6:30PM
7:00PM
7:30PM
8:00PM
Delivery Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Community Name (If needed)
Gate Code (If Needed)
Sold By (Dealer)
Dealer Name
*
Ordered By
*
Model Number
*
PO#
*
Please Select One
BR115 XW
BR135 XW
BR135 XW H/C
Pad Needed?
*
Yes
No
Hurricane Straps? (No Charge)
*
Yes
No
Tax Exempt?
*
Yes
No
Location (check all that apply)
*
Business/Shop
Near Pool Equipment
Driveway
Shipping
Which side of Property?
*
Left
Right
Haul Away Old Heater?
*
Yes
No
Disconnected?
*
Yes
No
Remove Box?
*
Yes
No
Remove Pallet?
*
Yes
No
Special Instructions
Who Do We Call for Delivery?
*
First Name
Phone Number?
*
When Should We Call?
*
On The Way
After Delivery
Is this a Two Man Delivery?
*
Yes
No
Any Other Notes For Us?
Name
This field is for validation purposes and should be left unchanged.
Δ
Home
About
Products
XW Pool Heaters
Locking Covers
Locations
Resources
Warranty
Support & Troubleshooting
Downloadable Resources
Request Forms
Info Request Form
Order Request Form
Service Request Form
Pay Bill
