Free Air Purifier

1. Since living in your area, do you think the air quality has gotten….
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Better
About the same
Worse
2. Does anyone in your home suffer from…
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Asthma
Allergies
Breathing problems
Other
3. Do you have Children or Pets?
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Children
Pets
Both
4. Are you…
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Married
Single
Co-Habitation
5. What line of work are you in?
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6. What line of work is your spouse in?
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7. What age group are you in?
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25 under
25-35
36-45
46-55
56-65
66-75
76+
8. Do you own or rent?
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Own
Rent
9. Contact information (We will contact you via telephone)
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10. Who referred you?
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If you are human, leave this field blank.

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