Radon Test Kit Order Form
Each radon test kit costs $6.50.
Kit #__________________________
(# To Be Entered by UGA representative upon completing order)

Homeowner Agreement

First Name:     MI:     Last Name:

Street Address of Home to Be Tested (required):

City:     State:     Zip Code:   Select Your County: Choose One Appling Atkinson Bacon Baker Baldwin Banks Barrow Bartow Ben Hill Berrien Bibb Bleckley Brantley Brooks Bryan Bulloch Burke Butts Calhoun Camden Candler Carroll Catoosa Charlton Chatham Chattahoochee Chattooga Cherokee Clarke Clay Clayton Clinch Cobb Coffee Colquitt Columbia Cook Coweta Crawford Crisp Dade Dawson Decatur DeKalb Dodge Dooly Dougherty Douglas Early Echols Effingham Elbert Emanuel Evans Fannin Fayette Floyd Forsyth Franklin Fulton Gilmer Glascock Glynn Gordon Grady Greene Gwinnett Habersham Hall Hancock Haralson Harris Hart Heard Henry Houston Irwin Jackson Jasper Jeff Davis Jefferson Jenkins Johnson Jones Lamar Lanier Laurens Lee Liberty Lincoln Long Lowndes Lumpkin Macon Madison Marion McDuffie McIntosh Meriwether Miller Mitchell Monroe Montgomery Morgan Murray Muscogee Newton Oconee Oglethorpe Paulding Peach Pickens Pierce Pike Polk Pulaski Putnam Quitman Rabun Randolph Richmond Rockdale Schley Screven Seminole Spalding Stephens Stewart Sumter Talbot Taliaferro Tattnall Taylor Telfair Terrell Thomas Tift Toombs Towns Treutlen Troup Turner Twiggs Union Upson Walker Walton Ware Warren Washington Wayne Webster Wheeler White Whitfield Wilcox Wilkinson Wilkes Worth

Mailing Address (If PO Box):

Daytime Phone Number:     Email Address:

Do you wish to receive our email Quarterly Radon Newsletter?     I plan to test: Basement First Floor

How did you learn of the UGA Radon Program?     Keep Georgia Beautiful Local County Extension Office Radon Educator Southface Medical Professional Realtor Builder TV Radio Newspaper Ga Dept. of Community Affairs Other Choose One

If Other, please explain:    

I agree to allow the University of Georgia Cooperative Extension to receive a copy of my radon test results. I understand that I may be contacted by a University of Georgia Radon Educator regarding my results to help me understand what I can do to reduce radon levels in my home and thus reduce the risk for lung cancer.

I Agree to the Above (Required)

Signature: ______________________________________ Date: __________________________

Print and Mail this completed form along with $6.50 check or money order payable to the University of Georgia. Mail to the Radon Educator designated for your county. Limit one kit per form - Limit two kits per home. Radon Test kits will be mailed to homeowner.