Rainmate

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* 1. Since living in your area, do you think the air quality has gotten....

Better

About the same

Worse

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* 2. Does anyone in your home suffer from...

Asthma

Allergies

Breathing problems

Other

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* 3. Do you have Children or Pets?

Children

Pets

Both

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* 4. Are you...

Married

Single

Co-Habitation

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* 5. What line of work are you in?

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* 6. What line of work is your spouse in?

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* 7. What age group are you in?

25 under

25-35

36-45

46-55

56-65

66-75

76+

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* 8. Do you own or rent?

Own

Rent

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* 9. Contact information (We will contact you via telephone)

Name

City/Town

State/Province

Cell Phone Number

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* 10. Who referred you?