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TLZ Rainmate Survey
Register for a chance to Receive a FREE fresh Air Machine
Free Fresh Air Machine ($249.00 Value) Helps with Allergies, Asthma, and Breathing Problem
(Survey open to North Carolina & Virginia residents Only)
OK
1.
Since Living in NC or VA, do you believe the air has gotten better, worse, or stayed the same.
Better
Stayed the Same
Worse
2.
Does anyone in your family suffer from asthma, allergies, or breathing issues?
Asthma
Allergies
Breathing Problems
3.
Do you have children and/or Pets?
Children
Pets
Both
4.
Your Martial Status?
Married
Single
Engaged
Living Together
5.
What do you do for work?
6.
What does your spouse / significant other do for work?
7.
Age Group?
18-25
26-35
36-45
46-55
56-65
66-70
71+
8.
Do you Own or Rent your home?
Own
Rent
Live with Parents
Other (please specify)
*
9.
Contact Information (We will contact you by phone or Text)
(Required.)
Your Name (First & Last)
*
Spouse/ Significant other Name
Address
*
City/Town
*
State/Province
*
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
Cell Phone Number
*
10.
Annual Household Income
Under $25,000
$25,000 - $50,000
$50,000 - $100,00
Over $100,000
11.
What day is best for delivery?
Tuesday
Wednesday
Thursday
Friday
Saturday / Sunday
12.
Who sent / referred you? (First & Last Name)
Current Progress,
0 of 12 answered