Survey Example Consumer Products Warranty Card Customer information, usage occasions, warranty identification information.

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Name	Consumer Products Warranty Card
Description	Customer information, usage occasions, warranty identification information.
Category	Product Surveys (Browse All Categories)

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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

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