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Name:
Phone:
Address:
Email:
City:
State:
Zip:
Please select from the following questions
What Is Your Status ?
Home Owner
Landlord
Management
Renter
Tenant Of The Area
Other, Explaiin
Type Of Property
House
Apartment
Town House
Office 1-3 Floors
Office 4 Floors Plus
School
Manufacturing Plant
Restaurant
Medical Facility
Auto Machanic / Body
Other, Explain
Age Of Dwelling ?
1-3 Years
3-6 Years
10 Years
20 Years
30 Years
40 Years
50 Years +
Other:
Other:
Has There Ever Been Water Damge On Your Premises
Yes
No
If Yes, Then How Long Ago
Please Describe The Damage Or Flood Incident
Is There Any Visible Mold On Walls, Floors Or Ceilings ?
Select
NO
Yes On The Walls
Yes On The Ceilings
Yes On The Floors
Yes All Over The Place
Is There A Smell Throughout The Property
No
Yes And It Smells Like
Mold
Sewer
Humid Muggy Smell
Moisture
Dusty Moist Smell
Rusty Pipe Smell
Dusty Dry Smell
An Unclean Smell
On A Scale Of 1 - 10 How Bad Is The Smell
Select
1 Not Bad
2
3
4
5
6
7
8
9
10 Very Bad
Do You Or Anyone Have Allergy Symptoms
No
Yes The Following Do
Infant 1-4 Years Old
Child 5-12 Years Old
Teenager 13-19
Adult 20=30
Adult 30-40
Adult 40-60
Senior Citizen
Only Some Of Us
All Of Us DO
Was A Physician Contacted About Your Symptoms
No
Yes
Is Anyone Pregnant On The Premises?
Yes
No
Has An Insurance Claim Been Filed ? If So, Who Is The Adjuster
In What Rooms And On Which Floor Or Floors Do You Suspect Mold
How Did You Hear About Us ?
Google Search
Yahoo Search
Other Internet Search
Recommendation
Newspaper
Our Vans
Other, Explain
Others
Comments, Questions etc..
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