Participating homeowners will receive a $50.00 Gift Card (your choice) for providing their honest opinions and valuable feedback on an exciting new product.

This is a voluntary marketing survey for a local business in your area which is not affiliated with your local municipal water treatment plant or any federal, state or local division of government.

This is purely a marketing survey/demonstration for which participants will be paid $50.00 (by way of gift card).

* = required field

Survey Code: (from mailed notice or door hanger) *
Sub Ref. Code: (below survey code) *	NCL NHO NBRN ATJ CNVS RGC RFRL
$50 Gift Card Choice *	Home Depot® Lowes® Walmart® Regal Cinemas® Outback Steakhouse® Macaroni Grill® AMC Theaters® Ruby Tuesday® iTunes® Applebee’s® Red Lobster® Pizza Hut® Olive Garden® Chilis® Cracker Barrel® Amazon.com® Starbucks® Facebook®
First Name: *
Last Name: *
Street Address: *
Suite or Apt. Number: *
City *
State *
Zip Code *
Phone (for Gift Card Redemption) *
Alt. phone (To Expedite Gift Card Redemption) *
I/We *	Own our residence Rent our residence
Number of adults at this residence: *	1 2 3 4+
Number of children at this residence: *	0 1 2 3 4+
Our water sometimes tastes/smells like: *	Chlorine    Stale    Other    Fishy    Metallic    None    Rotten Egg    Bitter    Muddy    Salty
Our water sometimes stains toilet, tub, sink, etc. *	Yes No
The color of our water is: *	Cloudy Rusty Milky Clear
Our water comes from: *	City Drilled Well Dug Well
I/We own the following water treatment devices *	Refrigerator Filter    Tap Filter    Water Softener    Shower Filter    RO Purifier
Do you drink bottled water? *	Yes No
How often do you drink bottled water? *	Often Sometimes Rarely Never
I/We (Head of Household) are: *	Employed Retired Other
Generalized Head of Household Age: *	18-29 30-39 40-49 50-59 60-69 70+
Generalized level of household income: *	0-25k 26-50k 50k+

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