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NOTE: CASE SENSITIVE NO SPACES
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:
*E-mail Address:
*Street Address :
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Pool Dealer/Builder:
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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:
Vinyl Liner Concrete Fiberglass
Inground Above-ground
Open Sky Domed Screened
(Please Select All that Apply)
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
If Other , Please Specify:
Additional Personal Info
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
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