Air Purification

Your Information (Required)

First Name:

Last Name:

Phone Number:

Email Address:

Your Partner (Optional)

First Name:

Last Name:

Phone Number:

Email Address:

Do you believe the air quality in recent years has...*

Improved Gotten worse Stayed the same

Does anyone in your home have any of the following...*

Asthma / Allergies Respiratory problems None

Is there children or pets in the home?*

Children Pets Neither

Which of the following applies to you?*

Single Married / Common-law Live in partner Dating but live separately

What you do for work...*

What your spouse/partner does for work...

Annual household income*

Under 25k 25k - 50k 50k - 100k Over 100k Rather not say

What age category do you fall into*

18-21 22-25 26-35 36-49 50-65 66+

My current living situation is...*

Home owner Renting Rent to own Living with family / others

How important is a clean home and air to you?*

Extremely Very Somewhat Sort of Not at all

Home Address

Full Address

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