Address where Pest Offense® is used:
City:      State:      Zip:
Mailing address (if different):
City:      State:      Zip:
Email address:
Number in household   Adults:      Children:
Do you have any indoor pets?:         If so, what kind?:
Pest Offense® will be used in:      
Type of Structure (if applicable):
Type of Construction (if applicable):
Location of Structure:
Approximate Age of Structure:
Condition of structure:         
How many levels does your structure have?:
Approx. date Pest Offense® was plugged in:      
How many units was Pest Offense® used in?:
Where did you plug the unit(s) in?:
Type of pest control used before Pest Offense®:
Do you still use another pest control inside along with Pest Offense®?:         If so, what kind?:
What type of Pests did you have?:
Frequency of seeing pests before plugging in Pest Offense®:
How long after plugging in Pest Offense® did you see results?:
Frequency of seeing pests after plugging in Pest Offense®:
Are you satisfied with the Pest Offense® product?:      
Please comment on your experience using the Pest Offense® product:
Would you recommend Pest Offense® to others?:      
Are you interested in other environmentally friendly products?:   
What else can we do to help you reduce the use of toxic chemicals in your life?:
How did you find us?: