2. Name*
3. Organization/Group (Optional)
5. Email Address*
6. Phone Number
8. City
9. Neighborhood/Community
11. What is your plan for using the air sensors; be specific (2-3 sentences).*
    For example, I want to use a purple air sensor over the winter to see how wood smoke effects my neighborhood compared to other areas. I will look at the difference between my sensor and nearby sensors at night when smoke levels are highest. Or, I want to borrow a Dylos to use as a teaching tool to help kids learn about air quality. We will walk around our neighborhood with the sensor and explore how air quality changes nearby roads.
13. Note: Monitors in the lending program cannot be used to extrapolate health risks or for regulatory compliance.
15. How do you plan to use the results?
17. Have you already been in contact with someone at the agency? If so, who?
19. Select one or more of the following:

    1. I want to use a monitor that doesn’t require a computer or phone
    2. I feel comfortable installing and configuring software on my computer
    3. I feel comfortable installing and configuring apps on a cell phone
    4. I feel comfortable following a tutorial that explains how to use Excel, Google Earth, or other software to analyze my data
21. Do you need help analyzing the data?

    1. Yes
    2. No
23. Select one type of monitor below:

    1. Dylos: used for measuring indoors and for walking/biking. Not weatherproof. 1-4 available for up to 1 month.
    2. Air Beam: used for mobile monitoring (walking/biking). Can connect to an Android phone only. Contact us if you need to borrow a phone. Not weatherproof. 1-4 available for up to 1 month.
    3. Purple Air: used for stationary air monitoring; weatherproof. Need 2.4-GHz Wi-Fi. 1-2 available for up to 4 months.
25. If you need more monitors or need to use them for a longer time please explain why below:
27. How many monitors would you like to borrow?
29. When would you like to pick up the monitors?
    When would you like to pick up the monitors?

    When would you like to pick up the monitors?
30. What date will you return the monitors?
    What date will you return the monitors?

    What date will you return the monitors?
32. I would like to (select one):

    1. Pick up the monitors at the Puget Sound Clean Air Agency building during business hours (8am – 4:30pm). Address: 1904 Third Ave NE, Suite 105. Seattle, WA 98101
    2. Have the monitors shipped to me. A pre-paid return shipping label will be provided.
34. Shipping address (if you selected “ship monitors to me”)
36. City
37. State
38. Zip Code
Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit Submit and Print

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