Please provide the following contact information (all fields MUST be completed):

First Name
Last Name
E-mail Address
Street Address
Address (cont.)
City
State/Province
Zip Code
Country
Home Phone

Please provide the following product information:

Model
Serial Number
Date Purchased
Retailer Purchased From
Type of Store
City & State Where Purchased
Price Paid

Please take a moment to give us your answers to the following questions.

                 This area must be filled in*

Can you get it to light	Yes     No
How long have you had the unit installed?
Who installed the unit?
Was it professionally installed?	Yes     No
If propane heater how big is your tank?
These questions are optional to give us more information about you Select Group Under 25 25-34 35-44 45-54 55-64 64 or older

Select One Emergency Heat Extra Heat Primary Heat
Select One Price Store Display Salesperson Recommendation Radio Ad Newspaper Ad Other (please specify)
What is your household income?	Select One Under $15,000 $15-30,000 $30-45,000 $45-$60,000 Over $60,000
Is it ok to contact you	Yes  No