Radon Test Kit Order Form
Each radon test kit costs $10.00.
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:

Mailing Address (If PO Box):

Daytime Phone Number:     Email Address:

I plan to test: Basement First Floor

How did you learn of the UGA Radon Program?    

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. Please note that test results may be available to other parties through the Georgia Open Records Act.

I Agree to the Above (Required)

Signature: ______________________________________ Date: __________________________

Print and Mail this completed form along with $10.00 check or money order payable to (see below). 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. Choosing your county from the drop-down box above will provide you with your radon agent below. Please note test kits are for Georgia residents only. We do not ship out of state.


OFFICE USE ONLY

Kit # ________________________________
Name: ______________________________
Signature of Radon Educator: _____________________________________

Date: ___________________
Amount Paid: $______________

This Radon Education Program is primarily funded by the US Environmental Protection Agency through the Georgia Department of Community Affairs.