Ebony Office Interiors

PERSONAL INFORMATION

Who referred you to this survey:

Street address:

*First Name

*Last Name

Office number:

*Email Address

City

Phone Number

()

State

Fax Number

()

Zip Code:

SPECIFIC FITTING DATA

Your weight:

Hip width (while seated, measure from hip to hip):

Your height:

Femur length (middle of hip to middle of knee):

Hours you sit per day:

Lower leg length (from mid knee to floor):

Which of the following represents the computer system you use?

Are you currently discomforted by a physical ailment?

If yes, please explain:

*Required Fields