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Title

First Name*

Middle Initial

Last Name*

Address*

Address (cont'd.)

City*

State*

Zip*

Email*

Email*

Phone Number

Date of Birth

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Purchase Date

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Previous Brand

Store Name

City of Retailer you Purchased From

State of Retailer you Purchased From

Which brand did you purchase?*

Select Model

Select Size

What type of base did you buy?

Price Paid

Three top reasons for selecting

Salesperson

Sales/Promotion

Quality

Previous Experience

Dealer Reputation

Value

Comfort

Brand Name

While shopping, where did you get your information?

(Check all that apply.)

Internet

Magazine

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Other

Newspaper

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