Information Request
Name
Address
City
State
Zip
Tel. #
Fax #
E-Mail Address
Best Time To Contact
Mornings
Afternoons
Evenings
Weekends
Best Way To Contact
Phone
Fax
E-mail
Reg. Mail
YOUR HOME HEATING INFORMATION
My main source of home heating is
Gas
Oil
Wood
Electric
Other
If Other, explain
Number of Fireplaces
one
two
three
Number of coal/wood stoves
one
two
three
Would you like us to contact you?
yes
no
I would like to setup an appointment for
Chimney Cleaning
Chimney Inspection
Chimney Relining
Other
If Other, explain
Questions or Comments . . . .
or E-mail us at:
sweeps@tri-countychimney.com