Request for Services - THE UTAH RADON COALITION

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Application for Free Radon Test
Information will be used for free radon test offer and will not be distributed for any other purpose.
(NOTE: BY APPLYING APPLICANT CERTIFIES THEY RESIDE IN HOUSE FOR WHICH THEY ARE REQUESTING A TEST)

Contact Information
Information will be used to distribute your free radon test, test result, and radon awareness information.

* Indicates required field

Date - MM/DD/YYYY *

Name *

First

Last

STREET ADDRESS / P.O. BOX *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number (000-000-0000) *

Email *

Please Tell Us the Location of Billboard Where You Learned of the Free Test Offer

Choose One *

1-15 1050 South (SLC) Northbound 1-15 (SR 270) (SLC) Southbound 1-80 Mile Mrkr 124 (South SLC) Eastbound 1-80 Mile Mrkr 124 (South SLC) Westbound 1-215 Mile Mrkr 18 (Wst Valley) Southbound SR 201 Mile Mrkr 14 (Wst Valley) Eastbound 1-15 9800 South (Sandy) Northbound 1-15 9800 South (Sandy) Southbound 1-15 Mile Mrkr 273 (Lindon) Northbound 1-15 Mile Mrkr 269 (Orem) Southbound 1-15 (American Fork) Southbound SR 79 31st St (St. George) Southbound

Please Tell Us the Date and Time You First Saw the Billboard Noted Above

Date - MM/DD/YYYY *

Time *

Please Tell Us What Attracted You to the Billboard

Choose One *

Color Radon Message Organization's Logos

Demographics
Information you provide will be compiled without your name and contact information and used to help us improve our free radon test billboard offer by identifying characteristics of persons who take advantage of such offers.

What is your Gender? *

Male Female Non-binary / third gender Prefer not to say

What is your age? *

18 - 24 25- 34 35 - 44 45 - 54 55 - 64 65 - 74 75 - 84 85 or Older Prefer not to say

What best describes your ethnicity? *

Asian or Pacific Islander Black or African American Hispanic or Latino Native American or Alaskan Native White or Caucasian Prefer not to say

What describes your education? *

Less than high school High school graduate Bachelor's degree Master's degree Ph.D or higher Trade school Prefer not to say

What is your marital status? *

Married Widowed Divorced Separated Never Married Prefer not to say

What is your housing situation? *

Paying a mortgage on home Own home outright Renting a home Prefer not to say

What is your yearly income level? *

Less than $25,000 $25,000 - $50,000 $50,000 - $100,000 $100,000 - $200,000 More than $200,000 Prefer not to say

Thank You - Please Press Below for Your Free Radon Test

Submit

RESOURCES

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Home owners guide to radon
Radon in Utah
Radon in your neighborhood
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Find a certified radon mitigator
Purchase a radon test kit

SERVICES

About radon awareness seminars
Register for a radon awareness seminar
About free or low-cost testing and mitigation
Apply for free or low-cost testing and mitigation

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© 2024 | The Utah Radon Coalition, a registered 501 (c)(3) public charity, EIN 47-1480033

Home
About Radon
About Radon in Utah
About Us
- Our Team
- BIOS
Services
Join Us
- Application For Membership
Donate
Contact Us