Complimentary Gift Card Survey

1

What source of water do you have?

3

When was the last time you had your water tested?

4

Do you currently use any type of water filtration?

YESNO

5

If yes:

6

Do you buy bottled water?

YESNO

7

To estimate water use, how many people live in your household?

8

How would you rate your water?

Excellent

Good

Fair

Poor

9

Do you rent or own your home?

10

Is there anything you would change about your water?

11

Name* This field is required.

First Name

Last Name

12

Home Phone* This field is required.

Area Code

Phone Number

13

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country