Register to Receive a Fresh Air Machine at NO COST! ($150 Value)
CLEAN AIR SURVEY
Email address *
KEEP YOUR HOME FRESH WITH OUR SCENT PACK
Do you believe the air quality in your area has gotten *
2. Does anyone in your household suffer from Asthma, Allergies, or Breathing Problems? *
Required
How many years have you lived in your area? *
Are there any children or pets living in your household? *
Required
Age Group *
What is your Marital status *
Do you own or rent your home? *
What do you do for work? *
What does your spouse do for work? *
Household Income: *
Are you looking for extra income? *
Name (First & Last) *
Spouse’s Name (First & Last): *
Street Address *
City/Town *
State *
Cell phone number *
Zip Code *
Best Time To Contact *
Do you prefer to be Called or Text to schedule the delivery date & time? *
Who's Social Media Post did you see this survey link on?(Please put first and last name so they get credit) *
If you are selected for the Rainmate from our company, we will reach out to the phone number you provided to set an appointment to deliver your Rainmate Fresh Air Machine. *
Required
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