| 1 |
* |
Required Fields |
|
| Model
Number |
Model 7000
|
|
Serial Number |
* |
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Date Purchased |
* |
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| 2 |
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| Name |
* |
|
|
| Address |
* |
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| City |
* |
|
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| State/Province |
* |
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| Country |
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| Postal Zip Code |
* |
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| Phone |
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| Fax |
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| E-mail |
* |
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3 How did you find out about
this product?
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4 The factors that influenced
your purchase?
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5 Primary reason for this purchase? (Check only one)
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6 This product will be used for?
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7 Your Occupation (Check
all that apply)
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Your Spouse's
Occupation
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8 Which describes your annual family income?
| 1 |
|
Under $15,000 |
4 |
|
$50,000 - $74,999 |
| 2 |
|
$15,000 - $29,999 |
5 |
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$75,000 - $99,999 |
| 3 |
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$30,000 - $49,999 |
6 |
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$100,000 + |
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9 Purchased from
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| 10 Your date of birth
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11 Excluding yourself, what is the gender and age (in years) of others living in
your household?
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| 12 Your marital status?
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13 Location of appliance?
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14 For your primary residence
do you?
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15 How many years have
you lived at this residence?
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16 Which of the following
Waterwise products do you currently own?
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17 Your level of education
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18 Which credit cards do
you use regularly?
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| 19 Please rate the following:
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Package Condition
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Package Appearance
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Product Appearance
|
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Use & Care Guide
|
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Completeness of Product
(All
parts & information included)
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20 Is anyone in your household
interested in any of the following?
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21 Please check all that apply to your lifestyle.
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22 Do you or
any family members have any of the following health
problems?
(Check all that apply)
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23 To help us understand our customers’ lifestyles, please indicate the
interests and activities in which you or family members enjoy participating on
a regular basis.
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Using the number in the above
list, please indicate the 3 most important activities
for:
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|
