Date

Costco Warehouse Number

Costco Name

Costco Address

State

Zip Code

Phone Number

Manager First Name

Manager Last Name

Title

Email (Separate Multiple Email Addresses With Commas)

How Many Scrubbers Do You Have?

Note: Head Size is measured across the width of both decks. ℹ

Select Scrubber Model #1

Select Head Size #1

Serial Number #1

Pad Size #1

Select Scrubber Model #2

Select Head Size #2

Serial Number #2

Pad Size #2

Select Scrubber Model #3

Select Head Size#3

Serial Number #3

Pad Size #3

Select Scrubber Model #4

Select Head Size #4

Serial Number #4

Pad Size #4

Select Scrubber Model #5

Select Head Size #5

Serial Number #5

Pad Size #5

First time users select your cleaner and pad sizes below, indicate how many months supply is requested

Starter-Pack includes pump, holder, and hoses

Cleaner Checkbox

Cleaner

Select Month

DTI Blue 20"

DTI Blue 20″

DTI Blue 20" Month

DTI Blue 18"

DTI Blue 18″

DTI Blue 18" Month

DTI Blue 17

DTI Blue 17″

DTI Blue 17" Month

DTI Blue 16"

DTI Blue 16″

DTI Blue 16" Month

DTI Blue 15"

DTI Blue 15″

DTI Blue 15" Month

DTI Blue 14"

DTI Blue 14″

DTI Blue 14" Month

DTI Blue 13"

DTi Blue 13″

DTI Blue 13" Month

Total

New SmartFloor User Request Form

Note: Head Size is measured across the width of both decks. ℹ

First time users select your cleaner and pad sizes below, indicate how many months supply is requested

Starter-Pack includes pump, holder, and hoses