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Assoc. -Group Name Owner Type: Select Owner Type Private Home Condominium Apartment Hotel/Motel Resort Mobile Home Park Public Pool Dealer Unit Industrial Country Club School Spa/Health Club Aquarium Other
*First Name / Middle Initial / *Last:Name:
*Address :
*City: *ST: Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Mississippi Missouri Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Select State *ZIP:
*Work Phone: *Home Phone: FAX:
*E-mail: Birthday Month / Day / Year
Occupation: Annual Household Income: Select Income Range Less Than $40,000 $41,000 to $50,000 $51,000 to $75,000 $76,000 to $100,000 $100,000 to $150,000 Over $150,000
For Pool Owners OUTSIDE The United States:
NATION: Select Country United States of America Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Ascension Island Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia & Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Islands Cayman Islands Central African Republic Chad Chile China (PRC) Christmas Island Cocos-Keeling Islands Colombia Comoros Congo Congo, Dem. Rep. of (former Zaire) Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Cuba (Guantanamo Bay) Curaçao Cyprus Czech Republic Denmark Diego Garcia Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Islands Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea (PRP) Guinea-Bissau Guyana Haiti Heard Island & McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Isle of Man Israel Italy Ivory Coast (Côte d'Ivoire) Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea (North) Korea (South) Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Republic Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Island Mexico Micronesia, (Federal States of) Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Réunion Island Romania Russian Federation Rwanda Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre & Miquelon Saint Vincent and the Grenadines Samoa San Marino São Tomé and Principe Saudi Arabia Senegal Serbia Seychelles Islands Sierra Leone Singapore Slovak Republic Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Islands Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands United States of America Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Islands Western Sahara Yemen Zambia Zanzibar Zimbabwe Province: Postal Code:
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Again No information will be released or used in any way without your express permission
TYPE OF PURCHASE:
1st Time Pool / Spa Heater Owner Replacement of Existing Heater Adding to Existing Heater
CURRENT HEATER
Type: None Heat Pump Nat'l Gas Propane Solar Elec.Resist. Oil Heater Brand Name:
WHY ARE YOU CONSIDERING HEAT SIPHON?
MAIN REASON(S):
Brand Reputation Service Reputation Friend Recommended Installer Recommended My Own Research
Price Warranty Corrosion Resistance Efficiency Quality
OTHER REASON:
SYSTEM INFORMATION
Type of System:
Pool Spa Pool /Spa Combo
Residential Commercial
Outdoor Indoor
Type of Pool/Spa: Please Select All that Apply
Vinyl Liner Concrete Fiberglass
Inground Above-ground
Domed Screened
Pool /Spa Sizes:
Pool Surface Area:
Sq Ft Sq M
Spa Surface Area:
Pool Volume:
Gallons Liters
Spa Volume:
Pool/ Spa Age:
Pick Age (yrs) New 1 yr 2 yrs 3 yrs 4 yrs 5 yrs 6 yrs 7 yrs 8 yrs 9 yrs 10 yrs 15 yrs 20 yrs Over 20 yrs
Pool/ Spa Cost:
Select Pool/Spa Cost Less Than $5,000 $5,000 to $6,000 $6,000 to $7,000 $7,000 to $8,000 $8,000 to $9,000 $9,000 to $10,000 $10,000 to $12,000 $12,000 to $15,000 $15,000 to $17,500 $17,500 to $20,000 $20,000 to $25,000 $25,000 to $30,000 $30,000 to $40,000 Over $40,000
How Did You FIRST Hear About Heat Siphon?
Heat Siphon Owner Pool Builder Pool Serviceman Pool Supply Co.
A/C Contractor Solar Contractor Friend Phone Book
Internet TV Magazine Radio
Mailer Newspaper E-mail Other
If Other , Please Specify:
YES, Please Have a Factory Salesperson Call Me YES, Please Find a Me Local Dealer I may Contact Keep Me on your mailing list for future reference
