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first name:
last name:
middle initial:
street:
city:
state:
zip:
phone: ( ) -
e-mail:
upc code (found on box):
where purchased?:
date of purchase: / /
 
how did hear of product:
does anyone in your
family have allergies?:
yes  
Which of the following would
influence your decision
to purchase air health?:
(select all that apply)
Allergies
Asthma
Mold
Odor
Air Quality
Reduce airborne germs       and bacteria
 
How old is your home?:
(years)
0-10
11-20
21-30
31+
 
place me on mailing list: yes