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Enter to Recieve a Free Personal Air Purifier
https://forms.gle/6TSfdRsYMhpv6SB46
1.
Who sent you or who's Facebook post did you click on? (First and Last name)
2.
Do you think the quality of the air you breath is?
Better
About the same
Worse
3.
Allergies/asthma/COPD
Yes
No
4.
Small Children
Yes
No
5.
Pets
Yes
No
6.
Does anyone in your household smoke?
Yes
No
7.
Age Group
18-24
25-34
35-44
45-54
55-64
65+
8.
Marital Status
Single
Married
Engaged
Living Together
Divorce
9.
If married, engaged or living together please put your spouse/significant other's name
10.
Do you Rent or Own your home?
Own
Rent
11.
What kind of work do you do?
12.
What kind of work does your spouse do?
13.
What is your annual household income?
$25,000-35,000
$35,000-45,000
$45,000-60,000
$60,000+
14.
Please Fill in all questions below:
Name
Address
City/Town
State/Province
ZIP/Postal Code
Country
Email Address
Phone Number
15.
The best time to deliver your FREE mini air purifier?
Morning
Afternoon
Evening
