East Systems Colleges of RizalMorong, RizalName (optional): ______________________________________________ Date: ______________________Address: ________________________________________________________________________________

Dear Customer:We, the proponents of Aqua Thirst Water Refilling Station are conducting a survey for us to provide quality drinking water and services that fit your needs and wants. We need your help in filing up this questionnaire. We appreciate your participation in this survey and welcome your feedback.

Direction: Answer the following question by putting a checkmark () on the box provided that correspond your answer.

1. Please indicate your age range. 18-24 25-34 35-54 55 or older 2. Please indicate your Gender. Male Female3. How many people are there in your family? 2 4Others (specify):_____ 3 54. Please indicate your household income. P8, 000 and below P15, 001 P 30,000 P50, 001 and higher P8, 001 P 15,000 P30, 001 P 50,0005. Aqua Thirst Water Refilling Station is currently attempting its establishment in Brgy. Quisao, Pililla, Rizal. Which best describes your opinion of these efforts? Very positive I have no opinion Very negative Somewhat positive Somewhat negative6. Would you consider patronizing a water refilling station if one were located in your barangay? Yes No7. Using the list below what factor/s would most influence you to patronize a water refilling station? Location Convenience Cost Quality services Kinds of drinking water Reputation of water station8. How aware you are regarding the safety and cleanliness of water you drink? Very much aware Aware Not much ware at all Much aware Not much ware 9. From what source does your drinking water comes from? Pililla Water District Deep well Others (specify): _________ Water pump Water refilling station 10. How frequently do you buy bottled water? Daily Once a week Once a month Twice a week Twice a month11. What size of bottled water do you buy normally? 330 ml 1.5 liters 1.5 gal 500 ml 3 liters 2.5 gal 1 liter 1 gal 5 gal12. How many bottles (330 ml) of water do you drink per day? 2 4 3Others(specify):_________13. In your household, how many bottles (5gal) of water do you consumed in a week? 2 4 3Others (specify):____________14. Which kind of water do you prefer to drink? Purified water Alkaline water Mineral water Distilled water15. Do you already have purified drinking water dealer? Yes NoIf yes please specify: ________________16. Do you agree for 30 minutes time span for the delivery? Yes No17. If we offer purified drinking water, are you willing to try? Yes No18. Will it be possible that you can be our first and loyal customer? Yes No19. How do you want us to reach you to take your order? Telephone/Mobile Online Personal