How did you find out about Screen Solutions?

Home Show		Friend/Neighbor
Magazine/Newspaper		TV/Radio
Other

Do you own a retractable screen? Yes No
If yes, what brand?

Number of retractable screens presently in your home:
Doors 1 2 3 4 5 more than 5
Windows 1 2 3 4 5 more than 5

If you already own a retractable screen installed by Screen Solutions, please provide an overall rating of the company's:
Sales & Service: Very Good Good Average Poor Very Poor
Installation: Very Good Good Average Poor Very Poor
Products: Very Good Good Average Poor Very Poor

The following information will be kept strictly confidential.

Name (optional):
Age:
Occupation:
Annual Family Income:	$
Value of Home:	$
Size of Home:
Home fully detached?	Yes No
Contact Info
E-Mail:
Tel.:	() -
Mail Address (optional):
City:
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