Customer Profile Survey.

Please provide your contact information. All fields are optional. Name   Title   Company   Street   City   State/Province   Zip/Post code   Country   Phone   Fax   Email   Please select your gender. Male Female Please select your age group. Please select one ... 20 and younger 21-25 26-35 36-45 46-55 56-65 66 and older Please select the number of members in your household. 1 person 2 people 3 people 4 or more people Please specify your ethnic or cultural background. African American Asian White/Caucasian Hispanic Native American Other   General purchase information: Brand   Product/Service   Model   Serial number   Department/Store   Address   City   How often do you use the [Product/Service]? Please select one ... Once a week or more often 2-3 times a month Once a month Every 2-3 months 2-3 times a year Once a year or less often Never Would you:   Yes No Do not know Please comment Use the product/service again Recommend the product/service to others Have you recommended to anyone? Please select one or more ... Our company Our product/service Your dealer Your sales person/agent Please rate your overall level of satisfaction with our [Product/Service]. Excellent Very Good Good Fair Poor Would you like to receive our free newsletter? Yes No What is the best way to contact you? By mail By phone By e-mail By fax Please do not contact Please provide any additional comments you may have.

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