Name: (*)

Address: (*)

City: (*)

State: (*)

Zip: (*)

Email: (*)

Phone Number: (*)

Cell / Alternate Number:

The following questions give us a better idea of what kind of system you're looking for. Please answer as many as possible.

What is the square footage of your home?

Can the vacuum in your home be exhausted outside (preferred method)?

Yes No

Please check which of the following you have in your home:

Wall to wall carpeting

Area rugs

Hardwood floors

Tile or laminate

Would you like a VacPan?

Yes No

Do you have pets that shed excessively?

Yes No

Which would you prefer?

Lower Cost Less Maintenance

Is your home currently roughed in for a central vacuum?

Yes No

Would you prefer to be contacted via e-mail or by phone?

E-Mail Phone

Comments / Questions / Special Requests: