City State Zip Code

Primary Phone (day) Alternate Phone

Email Address

Please check appropriate box Commercial Use Residential Use

If Commercial, What is the Company Name?

Purchase will be one of the following: Immediate, within the next 90 days, or within the next year.

Would you rather be contacted by, email or, phone?

How did you hear about our products?, Internet, Direct Mail Marketing, Word of Mouth,
Trade Show (If so which show?)

Comments or Questions

Thank you for your time in completing this brief questionnaire.