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Your Name *
Your Address *
How old are you? *
Which one best describes you? *
Do you have a pre-existing condition that is aggravated by heat? Please provide details *
Does your home or facility allow the installation of an AC unit? *
Can your window accommodate an AC unit installation?
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What is the best phone number to reach you? *
Is there a relative that we can contact to assist with the installation? (Please provide name, relationship and phone number)
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