Name:
Address:
Phone #:
Alternate Phone #
Email:
Gender:	Female     Male
Marital Status:	Single       Married     Divorced
Children:	Yes           No
How Many Children living in the household?:
How old are they?:
Do you own your own home?:	Yes           No
What branch in the military did you serve in?:
Did you serve in a combat situation?:	Yes           No
If so, where?:
Were you injured?:	Yes           No
If so, what injuries did you sustain?:
Do you have any ongoing medical conditions that resulted from combat?:
Why would you like a Home Improvement Makeover from Designing Spaces?:
If the Designing Spaces Dream Team came to your house, what room in the house would be your Ultimate Project Makeover?:
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