QuestionPro Survey

It would be most helpful if you would fill out the following information.

Mr.

Mrs.

Ms.

Miss

First Name

Last Name

Street Address

City, State and Zip

Date of Purchase

Model No. (See Box)

Type of store where purchased:

Department Store

Shoe Store

Clothing Store

Sporting Goods Store

Army-Navy/Work Store

Marina/Boating Store

Mail Order Catalog

Received as a Gift

Internet

Product Price Paid (excluding tax)

Please check the most important reason why you chose this product. (Check only one.)

Which of the following describes your purchase of (Product)?

First Time Buyer

Repeat Purchaser

Please check the primary occasion when you intend to use your new (Product/Brand). (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

What one factor most influenced your purchase of the (Brand)?

Date of birth of person whose name appears above: (Month and Year)

Marital Status:

Married

Divorced/Separated

Widowed

Single/Never Married

Do you have any children living at home in any of the following age groups?

Which group describes your annual family income:

Which types of credit cards do you use regularly?

American Express, Diners Club, Carte Blanche

Bank card (MasterCard, Visa)

Gas, dept. store, etc.

None of the above

For your primary residence, do you:

Own a house?

Rent a house or apartment?

Own a townhouse or condominium?