| 1 |
* |
Required Fields |
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Model Number |
Model 9000
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Serial Number |
* |
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Date Purchased |
* |
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| 2 |
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| Name |
* |
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| 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 |
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Under $15,000 |
4 |
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$50,000 - $74,999 |
| 2 |
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$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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