First Name Last Name
AREA OF MAIN CONCERN Air Quality Water Quality Both Air & Water Laundry Expense ALL 3 Areas Other Issues
City Nearest to you in Florida [Choose One] Orlando Winter Park Edgewood Belle Isle Eatonville Altamonte Springs Casselberry Longwood Lake Mary Sanford Windermere Oviedo Winter Springs Apopka Winter Garden Ocoee Deltona Deland Debary Orange City Lake Buena Vista Kissimmee Winter Haven Clermont Lakeland Leesburg WildWood Mount Dora Eustis Titusville Melbourne Palm Bay Ormond Beach Daytona Ocala Tampa Gainesville Clearwater St. Petersburg Sarasota Ft. Pierce West Palm Beach Okeechobee Stuart Jupiter Lake City St. Augustine Jacksonville Ft. Meyers Lake Worth Boca Raton Coral Springs Ft. Lauderdale Hialeah Miami Homestead Tallahassee Panama City Other - Not Listed
Street Address & City (if other above) ZIP Code
Phone Number E-mail Address
CLICK ON THE BOX(s) TO SHOW WHAT YOU/ANYONE Suffer From at your residence: Allergies Asthma Sinus Fatigue Depression
CLICK ON THE BOX(s) FOR ALL OF THE CONDITIONS THAT ARE PRESENT: Mold/Mildew Pets Snoring Smoke Odors Dust DustMites BadTastingWater WaterSmells UseAlotOfSoapToWash
Type of Residence House Apartment Condo Trailer
YOUR Residence is roughly how many square feet?
How Old is your residence approximately?
Heating Method (with ducts, fireplace, what?
Do you have A/C?(central air, window unit or none?)
Occupation [Select an Occupation] Accounting/Finance Computer related (other) Computer related (Internet) Consulting Customer service/support Education/training Engineering Executive/senior management General administrative/supervisory Government/military Homemaker Manufacturing/production/operations Professional (medical, legal, etc.) Research and development Retired Sales/marketing/advertising Self-employed/owner Student Tradesman/craftsman Unemployed/between jobs Other