Contact Information:

Contact Name (First):

Contact Name (Last):

Phone Number:

E-Mail Address:
e.g. (email@yourdomain.com)

Home Information:

Square Footage Of Home:

Two Story Home?

Yes No

Carpeted Stairs?

Yes No

Oriental Rugs?

Yes No

Types Of Floor In Your Home:

Wall To Wall Carpeting
Hardwood
Ceramic / Marble Tiles
All Of The Above

Carpet Thickness:

Flat Normal Thick

I Prefer A

Canister Upright Central Wet / Dry Any

Present Vacuum Brand:

If Other, specify brand:

I Have Children:

Yes No

I Have Pets

Yes No

I Suffer From Allergies

Yes No

Do You Own An Air Cleaner?

Yes No

Price Range:

$250 - $750 $750 - $1500

Any comments or questions?