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Name:
Title:
Company:
Street Address:
Mailing Address
(if different):
City:
State:
Zip/Postal Code:
Country:
Phone:
Fax:
E-mail Address:
Do you currently own any kind of water filter?

    Yes (Please specify which brand)

    No

Which of these types of water do you currently use for drinking or cooking purposes? (Check all that apply)

    Filtered
    Tap
    City
    Well
    Spring
    Other (Please Specify)

Do you currently use bottled water?

    Yes
      From store
      From machine
    No

If you do use bottled water, approximately how many gallons per month?

    1-3
    4-6
    7-10
    10+

How many other people do you know who use bottled water?

    1-3
    4-6
    7-10
    10+

Are you interested in options to tap or bottled water?

    Yes
    No

How many are in your household?

    1
    2
    3
    4
    5
    6+

Do you own or rent your home?

    Rent
    Own

Are you interested in a home-based business?

    Yes
    No

Are you interested in fund-raising opportunities for an organization or group that you would like to support?

    Yes
    No

Where did you hear about this contest?

    Newsgroup
    Riddle du Jour
    Starving Shirley
    ThreadTreader's
    Infoseek
    Yahoo
    Hotbot
    Lycos
    Altavista
    GoTo.com
    Northern Lights
    Webcrawler
    Excite
    Other (Please Specify)

How would you describe yourself? (Check all that apply)

    I live in a municipal area
    I live in a rural area
    Parent
    Very concerned about our water quality
    Haven't thought much about our water quality
    Frequent WWW Surfer
    Occasional WWW Surfer
    Likely to buy a product online
    Unlikely to buy a product online
    I'll buy anything online

As a resource for water filtration systems and issues, how would you rate the content of our site?

    Poor
    Fair
    Good
    Very Good
    Exceptional

Any comments? We'd like to hear what you have to say!

Yes, I would like to take advantage of your online services to Friends of Pure Water Network, where we share with you timely and up-to-date information on water and water-related news, technologies and products (usually sent monthly by email!)

Thanks, and Good Luck!


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