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November Giveaway - Home Water Survey
*
1.
Your Source of Water Supply?
(Required.)
Public
Well
*
2.
Is the color of your tap water?
(Required.)
Cloudy
Rusty
Milky
Clear
3.
Do you get a scummy ring in your tub?
Yes
No
*
4.
Do you get mineral deposits on your sinks & faucets?
(Required.)
Yes
No
*
5.
Does your water stain Bathroom Fixtures?
(Required.)
Yes
No
*
6.
Do your dishes look cloudy after going through the dishwasher?
(Required.)
Yes
No
*
7.
Do you buy bottled water?
(Required.)
Yes
No
*
8.
Do you own a water treatment system?
(Required.)
Yes
No
*
9.
Are you concerned about water quality?
(Required.)
Yes
No
*
10.
Number of Persons in household:
(Required.)
*
11.
Are you
(Required.)
Homeowner
Renter
*
12.
What do you dislike most about your water?
(Required.)
*
13.
What is your first name?
(Required.)
*
14.
What is your phone number?
(Required.)
*
15.
What is your email address?
(Required.)
*
16.
Do we have permission to contact you?
(Required.)
Yes - Enter me to win the November Giveaway and Contact me.
No - Don't enter me to win and do not Contact me.
