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  1. Name & Address:  
    * Title Mr.    Mrs.    Ms.    Miss
    * First Name Initial * Last Name
    * Street Apt. No. * City
    * State/Province * Zip/Postal Code
    * E-mail Address
  3. Your date of birth:
  5. Marital Status: Married Single
  7. Date of purchase: 
  9. Model # purchased:  044387 -

  11. Store name:
  13. What are the top three (3) reasons influencing the purchase of your product?
    Received as a gift
    Prior experience with
    Recommendation of Friend/relative
    Recommendation of Salesperson
    Product packaging
    Value for price
    Product features
    Special offer
    Ease of Operation
    Magazine advertising
    Newspaper advertising
    In-store display
    TV advertisement
  15. Which of the following products do you currently own or plan to purchase within the next 6 months?
      Own Intend to buy
    Coffee Maker
    Espresso Maker
    Coffee Grinder
    Pasta Maker
    Deep Fryer
    Toaster Oven/Broiler
    Slow Cooker
    Food Processor
    Mini Food Processor
    Stand Mixer
    Convection Oven
    Bread Maker
    Gelato Maker
    Juicer/Juice Extractor
    Indoor Grill
    Waffle Maker
    Percolator/Coffee Urn
    Ceramic Heater
    Oil-Filled Radiator
    Fan Heater
    Baseboard Heater
    Air Purifier
    Air Conditioner
    Floor Care Product
    Other Household Appliances
  17. If you received this product as a gift, please indicate the occasion.
  19. Do you currently own any other Products?
    Yes No
  21. Not including yourself, what is the GENDER and AGE (in years) of children
    and other adults living in your household?

    No one else in household Child under 1 year
    1. Male Female Age (in yrs):
    2. Male Female Age (in yrs):
    3. Male Female Age (in yrs):
    4. Male Female Age (in yrs):
  23. Occupation: (check all that apply)
      You Spouse
    Upper Management/Executive
    Middle Management
    Clerical/Service Worker
    Tradesman/Machine Operator/Laborer
  25. Are you or your spouse:  
      You Spouse
    A Homemaker?
    A Student?
    Self Employed/Business Owner?
    Working from a Home Office?
    In the Military?
    A Veteran?
  27. Which group describes your annual family income?
    Under $15,000
    $250,000 & over
  29. Level of education: (select highest level completed)
    Completed High School
    Completed College
    Completed Graduate School
  31. Which credit cards do you use regularly?
    American Express, Diners Club
    MasterCard, Visa, Discover
    Department Store, Oil Company, etc.
    Do not use credit cards
  33. For your primary residence, do you:
    Own? Rent?
  35. How recently did you move into your current residence?
    Within 30 days
    Within 1-3 months
    Within 4-6 months
    7 to 12 months ago
    Have not moved in the last 12 months
  37. Which of the following do you plan to do within the next 1-6 or 7-12 months?
    (select all that apply)
      1-6 Months 7-12 Months
    Buy/Lease a New Vehicle
    Buy/Lease a Used Vehicle
  39. Please check all that apply to your household.
    Shop by Catalog/Mail
    Shop via the Internet
    Member of Frequent Flyer Program
    Donate to Charitable Causes
    Own a Compact Disc Player
    Have a Dog
    Have a Cat
    Own a Wireless/Cellular Phone
    Speak Spanish
    Own an Apple/Macintosh Computer
    Own a CD-ROM Drive
  41. To help us understand our customers' lifestyles, please indicate the interests
    and activities in which you or your spouse enjoy participating on a regular basis.

    01. Bicycling
    02. Golf
    03. Physical Fitness/Exercise
    04. Running/Jogging
    05. Snow Skiing
    06. Tennis
    07. Camping/Hiking
    08. Fishing
    09. Hunting/Shooting
    10. Powerboating
    11. Sailing
    12. Grandchildren
    13. Needlework/Knitting
    14. Sewing
    15. Flower Gardening
    16. Vegetable Gardening
    17. Crafts
    18. Buy Prerecorded Videos
    19. Automotive Work
    20. Electronics
    21. Home Workshop/Do-It-Yourself
    22. Recreation Vehicles (RVs)
    23. Listen to Records/Tapes/CDs
    24. Avid Book Reading
    25. Bible/Devotional Reading
    26. Health/Natural Foods
    27. Photography
    28. Cultural/Arts Events
    29. Fashion Clothing
    30. Art/Antique Collecting
    31. Foreign Travel
    32. Cruise Ship Vacations
    33. Travel in USA
    34. Gourmet Cooking/Fine Foods
    35. Wines
    36. Stamp/Coin Collecting
    37. Collectibles
    38. Our Nation’s Heritage
    39. Real Estate Investments
    40. Stocks/Bond Investments
    41. Contests/Sweepstakes
    42. Casino Gambling
    43. Science Fiction
    44. Wildlife/Environmental Issues
    45. Dieting/Weight Control
    46. Science/New Technology
    47. Self-Improvement
    48. Walking for Health
    49. Watching Sports on TV
    50. Home Video Recording
    51. Moneymaking Opportunities
  43. Using the numbers in the above list, please indicate your 3 most important activities:
    I do not want to receive coupons, mailings, or other special offers

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    To clear the form, press this button:

    Failure to submit this registration will not diminish your warranty rights.

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