Manhattan (212) 534-MOLD Long Island (516) 627-MOLD Five Boros (718) 677-MOLD Toll Free 1(888) 5BORO-911 Email moldspecialist1@aol.com FOR CLIENT USE ONLY 1) Full Name of Client: 2) Address of Client: 3) Client's Phone Number: 4) Client's Email Address: 5) Are you the owner, landlord, management or the tenant of the area? 6) Type of Property in Need of Mold Inspection/Remediation (House, Apt, Office, School, etc.) 7) Was there ever a flood or water damage in the house? 8) If yes, How long ago? 9) Roughly, how old is the house? 1-3 years 3-6 years 10 years 15 years 20 years 40 years 50+ years 10) How many floors does the property have? (excluding basement) 11) Is there any visual mold on the walls/floors/ceiling? 12) Is there a smell throughout the property? 13) If yes, on a scale of 1-10 how severe is the smell? 1 2 3 4 5 6 7 8 9 10 14) What type of smell is it? Mold Humidity Moisture Sewer 15) Where did you hear about us? Recommendation Internet Newspaper 16) Why do you feel that you have a mold problem? 17) Allergies symptoms described by client: 18) Which member of household is experiencing these symptoms: 19) How many members reside in the household: 20) Was a physician contacted about these symptoms Yes No 21) Is anyone in the household pregnant? 22) Did you file an insurance claim: If Yes, Who was the adjuster? 23) In what room and on which floor do you suspect mold growth? Additional Comments: Client Signature (by typing your name you certify that the information is correct):

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