Personal Information Name: Address: City: State: Zip:  Phone: Fax: Work Phone: E-mail address: Roofing Information Age of Roof:         select one 1-5 yrs 6-10 yrs 11-16 yrs over 16 yrs Dont Know Current Type:         select one Cedar Shake Wood Shingle Asphalt Comp Tar and Gravel Cap Sheet other Dont Know How many layers of existing material:         select one 1 2 3 Who Know? Height:         select one One story Two story split/tri level higher New roof preference:         select one Cedar Shake Wood Shingle Asphalt Comp Tar and Gravel Cap Sheet Other Dont Know Manufacturer preference:         select one Elk Celotex U.S. Tile Tar and Gravel Other No preference How did you hear about us?:         select one Yellow Pages Radio Postcard Television Internet Search Friend Relative Neighbor saw truck Referral Other Comments: