Amaircare Website - Locate Dealer Form

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Friday, 09-May-2008 15:31:10 EDT
Toll Free: 1-800-268-7732

Dealer Location Request Form

To help us find the nearest/most convenient dealer for you, we would like to find out some information about you. Please fill out the following form and we will contact you.

First Name:

*Required

Last Name:

*Required

Address:

*Required

City:

*Required

State/Prov.

*Required

Country:

*Required

ZIP/Postal Code:

Phone #:

*Required

E-Mail

*Required

Which Product(s) are you interested in? (click any that apply) *Required

Portables		Centrals
If you want information on a specific product, select from the list below
XR-100	Roomaid	AWW-350	AWW-675
2500	3000	8500	10,000
6000V Cart	7500 Cart

What are you looking to buy : *Required
New System(s) or Replacement Filter(s)

Are you comfortable with buying an Amaircare Product online? *Required
yes no

The Following is OPTIONAL information:

Do you or anyone in your family suffer from:
Allergies, Asthma, Other Respiratory Problems

Where did you hear about Amaircare?

Is this purchase going to be for: Commercial or Residential use?
If Residential, will it be used in an: Apartment or a House?

Personal Verification
Please type in the letters/numbers shown in this image (case sensitive - do not use capital letters)
(This is to prevent automated programs from spamming.)

*Required

Thank you,

Original Code by: Contact Form Generator

"Cleaning the Air You Breathe!"