Consumer Products Warranty Card Survey Template

Customer information, usage occasions, warranty identification information.

Introduction text here.
First Name
Last Name
Street Address
City, State and Zip
Date of Purchase
Model No.
What type of store did you purchase this [PRODUCT] in?
Department Store
Shoe Store
Clothing Store
Sporting Goods Store
Army-Navy/Work Store
Marina/Boating Store
Mail Order Catalog
Received as a Gift
How much did [PRODUCT] cost (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 this purchase of [PRODUCT]?
Purchasing for the first time buyer
Purchasing again
Please check the primary occasion when you intend to use [PRODUCT](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 [BRAND] [PRODUCT]?
Radio Ad
Magazine Ad
Newspaper Ad
Friend's Recommendation
Salesperson's Recommendation
In-Store Display
Previous Ownership
Not sure
What is your birth date?
Marital status:
Single/Never Married
Do you have children in your household 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.
For your primary residence, do you:
Own a house
Rent a house or apartment
Own a townhouse or condominium

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