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Step 1

Please tell us what your living environment is like so that we may better understand your situation.

Type of Home:
     Stucco Vinyl Siding Wood Siding Concrete Brick Log Cabin Other...

If Other, what type of home?


Size of Home, in Sq Ft:


Years at this location:


Number of Residents in Home:


Years with Chronic Illness:


Number of Others In Home With Illness:


= Required

Please use the above tab to continue to the Step 2.

Step 2

Please tell us more about your home and the situations you are experiencing.

Hold down Control and click to choose more than one option.

Home Exterior and Landscape:
     Home built on high point of lot Walls show water damage Water collects in yard Water Flows toward home

Roof:
     Roof Leaks Gutters Installed Bird Damages

Attic:
     Wet Insulation Blown-In Type Insulation Rodent Damages

Home Interior:
     Interior Flooding Visible Water Stains on Ceiling Visible Water Stains on Walls Carpets have been wet Buckled Hardwood Flooring Leaking Water Pipes Leaking Sewer Pipes Insect Damages Rodent Damages Pet Damages

Basement/Crawlspace:
     Foul / Moldy Odors Stains on ceiling Carpets have been wet Exposed dirt floor Flooding or Mold

Water Problems:
     Leaking sewer pipes Leaking water pipes Leaking A.C. Drains Insect Damages Rodent Damages

HVAC System(s)
     HVAC System in Attic HVAC System in Basement Ductwork cleaned in the last 6 mo. Filters Replaced in the last 30 days

Air Filtration
     HEPA System Installed HEPA Maintained in the last 6 mo. Other Air Filtration Systems Installed Water Filtration System Installed

Please use the above tab to continue to the Step 3.

Step 3

You are almost done. We now need to know how to contact you.

Full Name:
E-Mail Address:
Day Phone:
Night Phone:
Address Line 1:
Address Line 2:
City:
State:	Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareColumbia (District of)FloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zipcode:

= Required