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  1. Name & Address:    
    *Title
       *First     Initial    *Last    
    *Street
       Apt 
    *City
       *State/Prov 
    *Zip/Postal
      
     Email
     Confirm Email
     Phone
    ( ) -
  2. Your date of birth:   
  3. Marital status:  
  4. *Date of purchase:           
  5. Product Purchased:  
  6. Name of store where purchased:   
  7. Did you:  
  8. A) If you purchased this product yourself, did you plan to purchase it before entering the store?
  9. Is this product:  
  10. How did you first become aware of this product?  


  11. What factors and features most influenced your decision to purchase 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 





    

  

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