*Name: 
Company Name:
*Street Address: 
*City: 
*State:
*Zip: 
*Phone: 
*Best Time to Contact:
*Email Address:  
*What age bracket are you in?




*Number of people in home/office: 
*Are you the property owner?
*What source of water do you have?
*Do you drink your tap water?
*Color of tap water?


*Have you noticed the following? (Check all that apply)







*Are you concerned about the lead in your water?
*Do you currently have any of the following filtration systems? (Check all that apply)



*Do you purchase bottled water?
*If yes, what type?
 

Free Water Test

Please fill out the form below for a Free Home Water Quality Test from Long Island Water Services.

There is no obligation. *All fields required unless specified.