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Rainmate
*
1.
Since living in your area, do you think the air quality has gotten....
(Required.)
Better
About the same
Worse
*
2.
Does anyone in your home suffer from...
(Required.)
Asthma
Allergies
Breathing problems
Other
*
3.
Do you have Children or Pets?
(Required.)
Children
Pets
Both
*
4.
Are you...
(Required.)
Married
Single
Co-Habitation
*
5.
What line of work are you in?
(Required.)
*
6.
What line of work is your spouse in?
(Required.)
*
7.
What age group are you in?
(Required.)
25 under
25-35
36-45
46-55
56-65
66-75
76+
*
8.
Do you own or rent?
(Required.)
Own
Rent
*
9.
Contact information (We will contact you via telephone)
(Required.)
Name
City/Town
State/Province
Cell Phone Number
*
10.
Who referred you?
(Required.)
Current Progress,
0 of 10 answered
