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Warranty Card Consumer Product Survey Template

Consumer product warranty card: customer identification, usage occasion, demographics.
   
 
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
 
Other
 
 
   
 
Product Price Paid (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 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)?
 
TV Ad
 
Radio Ad
 
Magazine Ad
 
Newspaper Ad
 
Friend's Recommendation
 
Salesperson's Recommendation
 
In-Store Display
 
Previous Ownership
 
Other
 
 
   
 
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?
 
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.
 
None of the above
 
   
 
For your primary residence, do you:
 
Own a house?
 
Rent a house or apartment?
 
Own a townhouse or condominium?
 
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