Customer Survey * indicates a required field.
First Name*		Last Name*
Address
City		State
Postal Code		Phone*
E-mail Address*		Customer No.
Home Description*	Single Family Mobile/Modular Home Vacation/Seasonal Apartment/Duplex Other	Other
Water Heater Fuel*	Electricity Natural Gas Propane Other
Your Interests*	Appliance Repair Home Energy Audits Local Internet Access Generator Maintenance Home Security Systems Long Distance Telephone
When was your water heater installed?		Before 1985 1985 - 1990 1991 - 1995 1996 - 2000 After 2000
When was your heating system installed?		Before 1975 1975 - 1980 1981 - 1985 1985 - 1990 1991 - 1995 1996 - 2000 After 2000
What is the age of the primary account holder?		Under 25 25 - 34 35 - 44 45 - 54 55 - 64 65 and Over
Do you own or rent your home?		Own Rent
Do you operate a business out of your home?		Yes No
Do you plan to build a house in the next three years?		Yes No
What are your favorite TV stations?
What are your favorite radio stations?
Who is your electric service provider?
How satisfied are you with your electric service provider?		Very Satisfied Satisfied Dissatisfied
Do you recall hearing anything in the past 6 months about Touchstone Energy?		Yes No
If so, where did you see or hear this information about Touchstone Energy?
Please give us your comments:

Version 4.1  Copyright © 2009 Apogee Interactive, Inc.    Terms & Conditions