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Take our 15 second survey to get your Free Air Cleaner
Sponsored By Air Quality Inc. 303-934-1770
No Purchase Necessary. CO, WY, UT, NE, KS and AR Residents only
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1.
Since Living in your current state do you believe the air has gotten
(Required.)
better
worse
or the same
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2.
Do you believe the Air is Worse
(Required.)
Inside houses and building
Outside
the same
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3.
What do you currently do for work?
(Required.)
4.
What does your Spouse currently do for work?
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5.
Age Group
(Required.)
18-25
25-30
30-40
40-55
55-65
65-70
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6.
Annual Household Income
(Required.)
under 25k
25k-50k
50k-100k
100k +
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7.
Does Anyone in your Family Suffer from: Asthmas, Allergies or Breathing Problems?
(Required.)
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8.
Do you have Dust Issues at home?
(Required.)
Yes
No
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9.
Housing Status?
(Required.)
Own
Rent
Live with Others
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10.
Do you have Children?
(Required.)
Yes
No
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11.
Do you have Pets (Dogs or Cats)
(Required.)
*
12.
Contact Information (We will contact you by phone)
(Required.)
First and Last Name
City/Town
Cell Phone Number (required)
Email Address
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13.
Who Referred you?
(Required.)