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Please rate the following characteristics of the service representative on a scale from 1 to 5, where 1 means poor service and 5 means excellent service. If you did not deal with a service representative, please select 6.
1
Poor
2
Fair
3
Good
4
Very Good
5
Excellent
6
N/A
Knowledge of the product
Courteousness
Willingness to help
Efficiency/quickness
Ability to complete transaction
 
 

Product Background

Which product or products did you purchase?
 
[PRODUCT1]
 
[PRODUCT2]
 
[PRODUCT3]
 
[PRODUCT4]

 
 
How did the product's price compare to your expectations?
Poor Fair Good Very Good Excellent
 
 
 
 
Why was the product purchased?
 
Purchased for self
 
Bought by someone else at my request
 
Gift from someone else
 
Family purchase
 
Business purchase
 
Other
 
 
 
 
Buying Experience


Where did you purchase [PRODUCT]?
 
[LOCATION1]
 
[LOCATION2]
 
[LOCATION3]
 
Other
 
 
 
 
Will you please give a brief description of any particular reason (or reasons)
why you choose to purchase [PRODUCT] at this [LOCATION] (instead of elsewhere)?
   
 
 
 
How many times have you purchased from [LOCATION] before?
(Enter 0 if you have not purchased from [LOCATION] before.)
   
 
 
 
How was your overall purchasing experience?
   
 
 
 
Would you purchase another product through the same means?
 
 
 
If you choose 'No' or 'Maybe' for the previous question, will you please
state any particular reason (or reasons)for your choice?
   
 
 
 
Pricing & Product Value

How much did you pay for your product (excluding tax)?
   
 
 
 
Did you use any coupons or receive a discount of any kind?
Yes No
 
 
 
How would you rate the overall value of this product?
1 - Very low value 2 3 4 5 - Very high value
 
 
 
Name
   
Address
   
City
   
State
   
Zip
   
Email
   
Phone
   
Fax
   
 
 
 
Questions Comments you might have:
   
 
 
 
Thank you for taking the time to complete this survey! Your results will help us serve you better.
 
Please contact [email protected] if you have any questions regarding this survey.
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