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FREE Fresh Air Machine ($200 value)
Thank you in advance for taking our survey. Please answer each question to qualify.
Your friend or a family member has made it possible for you to qualify for a FRESH AIR MACHINE. Subject to Company rules.
OK
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1.
Do you believe there is an air pollution problem?
(Required.)
Yes
No
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2.
Do you believe air pollution is worse indoors or outdoors?
(Required.)
Indoors
Outdoors
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3.
Does anyone in your household suffer from breathing problems?
(Required.)
Allergies
Asthma
COPD
Bronchitis
No Problems
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4.
Marital Status
(Required.)
Married
Single
Living Together
Divorced
Engaged
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5.
Do you own your home or rent?
(Required.)
Rent House
Rent Apartment
Own House/Condo
Own Mobile Home/Rent Lot
Own Mobile Home/Own Lot
Live with parents/family
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6.
What industry do you work in?
(Required.)
7.
What industry does your spouse/significant other work in?
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8.
Your age group
(Required.)
Under 21
21-30
31-45
46-60
61-70
71+
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9.
Annual Household Income
(Required.)
Under $31k
$32k-$42k
$43k-$100k
$100k+
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10.
Contact Information. Answer all fields to qualify. (We will contact you by phone within the next 24-48 hours)
(Required.)
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
Email Address
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11.
Contact Information
(Required.)
Phone Number
*
12.
Who Sent you the survey? Or whose Facebook did you see it on so they can get credit for sharing the survey?
(Required.)