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First Name
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Address 1
Address 2
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ESTIMATE AGE OF FURNACE
1-5 years
6-10 years
11-15 years
16-20 years
20+
not sure
SCHEDULE SERVICE or ANNUAL MAINTENANCE
schedule service
annual maintenance
APPOINTMENT DATE & TIME
DO YOU OWN OR RENT?
own
rent
MY PRIMARY HEATING FUEL IS
natural gas
propane
electric
fuel oil
I COOL MY HOME WITH
ductless A/C
heat pump
central A/C
window A/C
NATURE OF PROBLEM
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