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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:
*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:
Pool Dealer/Builder:
*E-mail: Birthday Month / Day / Year
For Pool Owners OUTSIDE The United States:
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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:
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
