Fillable Automatic Filter Reorder Program

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Automatic Filter Reorder Program

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Replace Your Filter At Least Once A Year For Healthy, Delicious Water!
Automatic Filter Reorder Program
To maintain the high quality of your Multipure water, change your lter one or more times per year.
You can save up to 15% through Multipure’s convenient autoprogram!
* Your phone number and email address are requested so we can contact you in the event we have a question about your auto order or
credit card information. Please be assured that Multipure does not share its customer information with anyone.
By Signing this form you agree to have a lter shipped to you at the time interval you specied above and that your credit
card account will be charged for the lter, sales tax, and shipping. You agree to notify Multipure International of any change
in address or credit card account information in a timely manner so as to avoid unnecessary costs in processing and shipment.
City
Auto Shipment Frequency (specify 6 to 12 months)
Email
State
Date To Start Auto Shipments
Zip
Customer Name
Address
Original Order # (if known)
Phone
Email
Quantity (# of lters per shipment )
Authorized Signature Date
Return this form with your payment to:
Multipure International • Attn: Order Processing
P.O. Box 34630, Las Vegas, NV 89133-4630
Card Number Expiration Date CVV2 (three digit # on back of card)
Billing Address
(If different from above)
Visa Mastercard AMEX Discover
TYPE OF FILTER
NOTES
TOTALPRICERETAIL DISCOUNT
PRICES ARE IN U.S. CURRENCY, PLEASE PAY IN U.S. CURRENCY • PRICES ARE SUBJECT TO CHANGE WITHOUT PRIOR NOTICE
Subtotal
Add Local Sales Tax
Add Shipping
Total Amount Due
click to sign
signature
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FILTER
FILTER
DISCOUNT PRICERETAIL
CONTINENTAL U.S.
(Standard Mail)
HI, AK, PR
(Priority Mail)
CANADA
(U.S/CN Mail)
DISCOUNT
Aquaperform Filter
(CB11ASD for MP880xx)
Aquaversa Filter
Aqualuxe Filter
(CBLX for AQUALUXE Unit)
Aqualuxe Filter
RO Sediment Pre-Filter
(CBC110 for ROWattsPlus)
RO Sediment Pre-Filter
Aquasource Chlorine Filters (CB20 for AQSOURCE2)
Whole House Filter
Whole House Filter (CB20 for TO15000 & TO30000)
Aqualuxe Filter - WiFlow Discount (ONLY through WiFlow registration)
Aquaperform Filter
RO Membrane
(CB-ROM for ROWattsPlus)
RO Membrane
Aquaversa Filter
(CB6D for MP750xx & MP1200)
RO Carbon Block Pre-Filter
(CBC112 for ROWattsPlus)
RO Carbon Block Pre-Filter
Aquasource Chlorine Filters w/ Scale Reducer
(CB20LSI for AQSOURCELSI2)
Aquasource Chloramine Filters
(CB20CLM for AQSOURCECLM2)
Aquasource Chloramine Filters w/ Scale Reducer
(CB20CLMLSI for AQSOURCECLMLS)
Aquamini Filter
RO Carbon Block Post-Filter
(CB6RO for ROWattsPlus)
RO Carbon Block Post-Filter
Aquamini Filter
(AQUAMINI1D for AQUAMINI1)
Aquasource Filters
Aquashower Filter
(AQSF for AQSH Unit)
Aquashower Filter
MP400PC/MP400PCE Filter (CB5 for MP400PC, MP440PCE, & MPC250)
MP400PC/MP400PCE Filter
20%
15%
15%
15%
N/A
15%
15%
N/A
N/A
15%
15%
N/A
N/A
15%
15%
15%
$120
$127.50
$106.25
$38.25
N/A
N/A
N/A
$51
$306
$102
$59.50
N/A
N/A
$357
$357
$408
$150
$150
$10 1st + $4.50 ea. Add’l
$10 1st + $4.50 ea. Add’l
$10 1st + $4.50 ea. Add’l
$10 1st + $4.50 ea. Add’l
$38 (sold as set of 3)
$10 ea.
$7.75 ea.
$8.75 ea.
$10 1st + $4.50 ea. Add’l
$10 1st + $4.50 ea. Add’l
$10 1st + $4.50 ea. Add’l
$13 ea.
$15 1st + $8.25 ea. Add’l
$18 1st + $12 ea. Add’l
$15 1st + $8.25 ea. Add’l
$12 1st + $5.25 ea. Add’l
Not Available
$17 ea.
$12 ea.
$12 ea.
$15 1st + $8.25 ea. Add’l
$12 1st + $5.25 ea. Add’l
$12 1st + $5.25 ea. Add’l
$39 ea.
$36 1st + $12 ea. Add’l
$40 1st + $15 ea. Add’l
$36 1st + $12 ea. Add’l
$35 1st + $10 ea. Add’l
Not Available
$17 ea.
$12 ea.
$16 ea.
$36 1st + $12 ea. Add’l
$35 1st + $10 ea. Add’l
$35 1st + $10 ea. Add’l
$57 ea.
$125
$45
$16
$60
$70
$103
$70
$360
$120
$8.50
$27
$420
$420
$480
Aquadome Filter
$10 1st + $4.50 ea. Add’l $15 1st + $8.25 ea. Add’l $36 1st + $12 ea. Add’l
7251 Cathedral Rock Drive, Las Vegas, NV 89128 • 800.622.9206
Order Department: 800.622.9208 • www.multipure.com
0719
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Automatic Filter Reorder Program

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Completed 18 April 2021

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