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Introduction text here.
 
 
 
First Name
   
 
 
 
Last Name
   
 
 
 
Street Address
   
 
 
 
City, State and Zip
   
 
 
 
Date of Purchase
   
 
 
 
Model No.
   
 
 
 
What type of store did you purchase this [PRODUCT] in?
 
Department Store
 
Shoe Store
 
Clothing Store
 
Sporting Goods Store
 
Army-Navy/Work Store
 
Marina/Boating Store
 
Mail Order Catalog
 
Received as a Gift
 
Internet
 
Other
 
 
 
 
How much did [PRODUCT] cost (excluding tax)?
   
 
 
 
Please check the most important reason why you chose this product. (Check only one.)
 
Attribute 1
 
Attribute 2
 
Attribute 3
 
Attribute 4
 
Attribute 5
 
Attribute 6
 
Attribute 7
 
Attribute 8
 
Attribute 9
 
Other
 
 
 
 
Which of the following describes this purchase of [PRODUCT]?
 
Purchasing for the first time buyer
 
Purchasing again
 
 
 
Please check the primary occasion when you intend to use [PRODUCT](check only one.)
 
Usage occasion 1
 
Usage occasion 2
 
Usage occasion 3
 
Usage occasion 4
 
Usage occasion 5
 
Usage occasion 6
 
Usage occasion 7
 
Usage occasion 8
 
Other
 
 
 
 
What one factor most influenced your purchase [BRAND] [PRODUCT]?
 
TV Ad
 
Radio Ad
 
Magazine Ad
 
Newspaper Ad
 
Friend's Recommendation
 
Salesperson's Recommendation
 
In-Store Display
 
Previous Ownership
 
Not sure
 
Other
 
 
 
 
What is your birth date?
   
 
 
 
Marital status:
 
Married
 
Divorced/Separated
 
Widowed
 
Single/Never Married
 
 
 
Do you have children in your household in any of the following age groups?
 
None
 
Baby under 6 months
 
Baby 6 to 12 months
 
Age 1
 
Age 2-4
 
Age 5-7
 
Age 8-10
 
Age 11-12
 
Age 13-15
 
Age 16-18
 
 
 
Which group describes your annual family income?

 
Under $25,000
 
$25,000-$39,999
 
$40,000-$54,999
 
$55,000-$69,999
 
$70,000-$84,999
 
$85,000-$99,999
 
$100,000-$114,999
 
$115,000-$129,999
 
$130,000-$149,999
 
$150,000 & over
 
 
 
Which types of credit cards do you use regularly?
 
American Express, Diners Club, Carte Blanche
 
Bank card (MasterCard, Visa)
 
Gas, dept. store, etc.
 
Other
 
 
 
 
For your primary residence, do you:
 
Own a house
 
Rent a house or apartment
 
Own a townhouse or condominium
 
Other