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First Name:
Last Name:
Address:
City:
State:
ZIP:
Phone:
Email:
Check One: Male
Female
Age: 25-34
35-45
46-54
55+
I: Own
Rent
Type of residence:
Size of residence:
Estimated value of home:
Household Income:
Are you planning
home improvements?		 Yes
No
In the next: 6 months
12 months
18 months
Appliances Garage Storage Paving Stones
Awnings Gas Insert Pest Control
Barbecue/Outdoor Granite Countertops Plumbing
Bathroom Remodel Heat/Air Rain Gutters
Brick/Masonry Home Accessories Refinance
Cabinets Home Entertainment Retaining Wall
Carpet Home Office Roof Repair
Carpet Clean Home Security Room Addition
Central Vaccuum Insulation Sell/Purchase Home
Closet Insurance Shelving
Concrete Interior Paints SkyLights
Decorating Interior Redesign Stairways/Railing
Doors Kitchen Remodeling Sunrooms
Draperies Landscape Swimming Pool/Spa
Exterior Paint Lighting Tile Countertops
Exterior Redesign New Furnishing Tile Work
Fencing New Home Construction Wall Art
Fireplace Paint Wall Covering Window Replacement
Framing Patio Covers Wood Flooring
Garage Flooring Patio Decking Other
Please don't send me information about home improvements.