Max Energy Systems The MAX Solution Power Outages MAX Options Customer Care Customer Testimonials FAQS
     
Home Questionnaire
     
First Name*
   
Last Name*
   
Home Address*   
   
City
   
State
   
Zip*
   
Home Phone
   
Cell Phone
   
Office Phone
   
Email*
   
Date*
   
* Required  
 
How did you hear about us?
Friend
Radio
MAX Subcontractor
MAX Customer
Web Search
Direct Mail
Other
 
Estimate the number of power outages you have experienced in the last 12 months lasting less than 8 hours:
None
1-4 Power Outages
5-8 Power Outages
9-12 Power Outages
12+ Power Outages
 
Estimate the number of power outages you have experienced in the last 12 months lasting for more than 8 hours:
None
1-4 Power Outages
5-8 Power Outages
9-12 Power Outages
12+ Power Outages
 
Estimate the number of consecutive days you have been without electric power in the last 12 months:
None
1 Day
2 Consecutive Days
3 Consecutive Days
4+ Consecutive Days
   
How is your home heated?
Gas
Oil or Propane
Electric Heat Pump
Electric Furnace / Baseboard
Other
Not Sure
 
Do you need medical equipment on backup?
Yes
No
 
What level of power backup is of interest to you?
Entire house including heating and cooling
Outlets / lights in all rooms, most appliances, heating,
        and some cooling
Outlets / lights in several rooms, critical appliances, and heating
A few outlets / lights and critical appliances
Not Sure
 
Select the type of system that appeals to you the most:
A noise-free and service-free indoor battery system that provides
        8 -12  hours of backup power (with the option of plugging in a
        portable  gasoline generator for extended hours)
An outdoor gas or propane generator that provides multiple days
        of backup power
Not Sure
 
Would you like to set up an appointment for a free evaluation of your power backup needs?
Yes
No
 
Would you like to receive information by email on new backup power developments and special promotions by MAX Energy Systems?
Yes
No
 
 



Back