GOULDS WATER TECHNOLOGY DIVISION
Xylem Employee Internet Access Sign-Up Form
(Use this Sign-Up only if you are an Xylem Employee)


*Red fields indicate mandatory fields
Salesman #: - (If a Salesman)
Name: *
Title:
Company Name: *
Address: *
City: *
State: *
Postal or Zip Code: *
Country or Region: *
Email Address: *
Telephone No: *
Additional Address Information:
Message to Goulds:

Check the applications you would like access to:
Order Status Warranty Claims (Inquiry Only)
Product Availability Warranty Claims (On-Line Processing)

In order to ensure that this is not coming from some automated process:
We require that you re-type the following Random numbers and Letters:
MG