| First Name: |
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| Last Name: |
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| Street Address: |
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| City: |
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| State: |
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| Zip: |
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| Home Phone: (Please include all 10 digits) |
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| Cell Phone: (Please include all 10 digits) |
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| Email: |
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| Are you a homeowner? |
Yes
No |
| How many people are in your household? |
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| Which of the following do you use in your home? |
Drinking Water Filter
Water Softener
Air Purifier |
| Do you use bottle water? |
Yes If Yes:
Store Bought
Delivered
No |
| Would you rate the overall water quality in your home? |
Good
Fair
Poor |
| Which credit cards do you use? |
MC
VISA
AMEX
DISCOVER
OTHER |
| What is your age group? |
18-30
31-45
46-65
66+ |
| |
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