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* 1. Does anyone in your home suffer from any of the following? (Select all that apply)

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* 2. Do you have any of the following? (Check all that apply)

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* 3. About how much do you spend monthly on cleaning supplies for your home? (Wax melts, Febreze, Plug ins, scentsy, swiffer pads, candles, filters, etc.)

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* 4. Are you employed?

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* 5. Do you own or rent your home?

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* 6. Marital Status

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* 7. Full address:(number, st, city, state, and zip code)

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* 8. Your First and Last Name

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* 9. Phone number

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* 10. If selected to receive a Free Purifier, how soon would you like it?

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