Step 6 · Order Intake

Order & Purchase Intake Form

Co-branded BioHydroH2O / Vitality Water Systems (VWS) order intake — used to accurately record and route your request. This is not the final purchase agreement.

Dealer Intake Only — Not a Binding Sale

BioHydroH2O and On-Line Selling Systems, LLC are an independent authorized dealer for Vitality Water Systems (VWS). This form exists so BioHydroH2O can accurately record and report orders — it is not the final purchase agreement, does not process payment, and does not obligate you to buy.

VWS is the manufacturer and seller of record. VWS processes and collects all payment, issues the final signed purchase agreement, sets financing terms, and provides and honors the product warranty. Pricing shown below is a good-faith estimate; VWS will confirm final pricing, taxes, and terms directly with you before any charge is made.

BioHydroH2O assumes no liability for VWS's order processing, financing decisions, shipping, or warranty performance — all such matters are between you and VWS.

Customer Information

Please print clearly — this is used for reporting to VWS.

Date*

Full Name*

Spouse / Co-Buyer

Email*

Main Phone*

Alternative Phone

Street Address*

Apt / Unit #

City*

State*

Zip*

Shipping Address (if different)

System & Phase Selection

Select the phase(s) of the whole-home system being ordered. Pricing is an estimate Placeholder — VWS confirms final pricing.

Description	Est. Price




Estimated Taxes
Estimated Shipping / Install
Estimated Total

Notes

How You'd Like to Pay

No payment is collected here. This tells VWS how to follow up with you.

Preferred payment method (VWS will contact you to process)

Cash / Check Credit / Debit Card VWS Financing Not Sure Yet

Special Terms / Requests

Sales Representative / Referral

Used for BioHydroH2O's internal commission and QR-attribution tracking only.

Consultant / Rep Name*

Rep ID / QR Code

Electronic Signature

This is your electronic acknowledgment that the information above is accurate — not a purchase contract. VWS's own agreement governs the actual sale.

Type Your Full Legal Name*

Draw Your Signature*

Signature, typed name, and timestamp are recorded together as your electronic signature under the U.S. ESIGN Act.

I acknowledge this is a BioHydroH2O dealer intake form, not a binding purchase agreement, and that Vitality Water Systems (VWS) will contact me directly to finalize payment, financing, delivery, and warranty terms.

Order Intake Received

Thank you — your request has been recorded by BioHydroH2O for order tracking. Vitality Water Systems (VWS) will contact you directly to finalize pricing, payment, financing, and delivery. No payment has been taken.

Reference ID: — · Keep this for your records.

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