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.
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
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
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)?
Radio Ad
Magazine Ad
Newspaper Ad
Friend's Recommendation
Salesperson's Recommendation
In-Store Display
Previous Ownership
Date of birth of person whose name appears above: (Month and Year)
Marital Status:
Single/Never Married
Do you have any children living at home in any of the following age groups?
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
$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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