MINI PURIFIER SYSTEM SURVEY

Please fill out this brief survey for your chance to recieve a FREE Air Cleaner

Does anyone in your home suffer from Ashthma/Allergies/COPD?

Asthma

Allergies

COPD

All of the above

Do you have any children or pets in the home?

Children

Pets

Both

Are you Married or Single? (If living together in a commited relationship please select Married)

Married

Single

What field of work are you in?

What field of work is your partner in?

Do you Rent or Own?

Own (Paying on Mortgage)

Own (Paid off)

Renting

Name

Phone Number

City

State

Name of the person who referred you to the survey?

Verification

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