Enter For Free Air Cleaner

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* 1. DOES YOUR HOUSEHOLD HAVE (Select all that applies)

Children

Pets

Allergies/ Asthma/ Other breathing issues

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* 2. WHICH AGE GROUP ARE YOU IN?

Under 18

18-24

25-29

30's

40's

50's

60's

70+

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* 3. MARITAL STATUS

Single

Married

Live with a significant other, but not married

Widowed

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* 4. WHAT IS YOUR CURRENT LIVING SITUATION?

Own Home

Rent Home

Rent Apartment

Live in Mobile Home Park

Live with family or friends

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* 5. WHAT DO YOU DO FOR WORK?

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* 6. WHAT DOES YOUR SPOUSE/PARTNER DO FOR WORK?

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* 7. NAME

First name

Last name

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* 8. ADDRESS

Street address

UNIT NUMBER (if applicable)

City

State

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* 9. PHONE NUMBER (WE DO NOT SHARE YOUR INFORMATION. WE ONLY CONTACT YOU IF YOU'RE SELECTED)

Phone Number

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* 10. SPOUSE/ PARTNER'S NAME (IF APPLICABLE)

First name

Last name

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* 11. How did you hear about us? (name of FB friend or event/venue where you entered)

First name

Last name