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Business Questionnaire
     
First Name*
   
Last Name*
   
Company  
   
Office Address*
   
City
   
State
   
Zip*
   
Office Phone
   
Cell Phone
   
Email*
   
Date*
   
* Required  
 
How did you hear about us?
Friend
Radio
MAX Subcontractor
MAX Customer
MAX Web Site
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 office / business heated?
Gas
Oil or Propane
Electric Heat Pump
Electric Furnace / Baseboard
Other
Not Sure
 
Is your office / business in a high rise building?
Yes
No
 
What level of power backup is of interest to you?
Entire office including heating and cooling
Outlets / lights in all rooms, most office equipment, and heating
Outlets / lights in several rooms, critical office equipment,
        and heating
A few outlets / lights and critical office equipment
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
 
 



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