Do you currently have a water treatment system?	Yes No
If so, is it a Culligan system?	Yes No
Do you have a well or city water?	Well City
Do you currently drink bottled water?	Yes No
What, if any, problems have you noticed with your water?
Have you ever had your water tested?	Yes No
Where do you live? (Please supply your full address and phone number)
Do you rent or own your home?	Rent Own
What is your name?
Are you over 18 years of age?	Yes No
What is your email address?
What is the best way and time to contact you regarding your contest entry?
If selected, would you be willing to do a live testimonial on the radio?	Yes No

**Official Contest rules are available at:
Culligan Water Conditioning located at 1222 W. Greenleaf Street, Allentown, PA 18102