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  1. Name & Address:    
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  2. Your date of birth:   
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  4. *Date of purchase:           
  5. *Model number:    
  6. Name of store, catalog or internet site where purchased:   
  7. Price paid (excluding sales tax):   
  8. Did you:  


  9. Is this product:  



  10. Which of the following brands did you seriously consider before purchasing this product? 



  11. Is this product:  



  12. Which group describes your annual family income?  
  13. Level of education:  
  14. For your primary residence, do you:  

  15. Occupation: (check all that apply) 
  16. Lifestyles