Name:   *

 Address: *

 City, State, Zip: *

 Home Phone: *

 Cell Phone:

 E -mail:   

 1. Are you the home owner? ----- Yes No

 2. Square footage of home?

 3. Age of home?

 4. Age of system?

 5. Is your unit operational? ----- Yes No

 6. Current unit type? ----- Gas Electric Propane Oil

 7. Install Type? ----- System AC Furnace Boiler Mini Split Accessories Duct Work Service Other

 8. When are your looking to replace your equipment? ----- ASAP 1 to2 months 6 months Within a year

 9. Will you self-finance or do you prefer other financing? ----- Self Credit Card Other

 10. When is the best time to contact you? ----- Morning Afternoon Evening

 11. Is it o.k. to call you at work -- Yes No if yes, #?

 12 . Unit age ----- less than 10 years More than 10 years

 13. Utility Bills ----- Happy O.K. Unhappy

 14. Dust and Allergies ----- Good Fair Poor

 15. Comfort Level ----- Good Fair Poor

 16. Reliability ----- Good Fair Poor

 17. Noise ----- Loud Average Quiet

 18. Maintenance ----- Yearly Never

 Comments: