| First Name |
|
| Last Name |
|
| Address |
|
| City |
|
| State |
|
| Zip Code |
|
| Telephone |
|
| Email |
|
| |
|
| Type of product purchased |
|
| Rice Cooker |
|
| Blender |
|
| Toaster Oven |
|
| Toaster |
|
| Electric Grill / Skillet |
|
| Water Heater |
|
| Coffee Maker / Urn |
|
| Deep Fryer |
|
| Dehydrator |
|
| Ice Cream Maker |
|
| Juicer |
|
| Electric Wok |
|
| Potpourri Pot |
|
| |
|
| Product Model Number |
A- |
| |
|
| |
|
| Is it a gift? |
Yes
No |
| If not, where was it purchased? |
|
| Purchase price |
|
| |
|
| What are the factors affecting your purchase? |
Check all that apply |
| Brand reputation |
|
| Price |
|
| Specific Features |
|
| Style or appearance |
|
| Recommendation from a friend |
|
| Other reason |
|
| |
|
| Is this the first time obtaining this type of product? |
Yes
No |
| If not, is this the first time obtaining this type of product of the Aroma brand? |
Yes
No |
| |
|
| Marital Status |
Married
Single |
| |
|
| Date of Birth |
Month Year |
| |
|
| Your Primary Occupation |
Check one each |
| Professional / Technical |
You
Spouse |
| Upper Management / Executive |
You
Spouse |
| Middle Management |
You
Spouse |
| Sales / Marketing |
You
Spouse |
| Clerical / Administrative |
You
Spouse |
| Tradesman / Machine Operator |
You
Spouse |
| Service |
You
Spouse |
| Laborer |
You
Spouse |
| Retired |
You
Spouse |
| Student |
You
Spouse |
| Self employed |
You
Spouse |
| Military |
You
Spouse |
| Homemaker |
You
Spouse |
| Other - You |
|
| Other - Spouse |
|
| |
|
| Which group best describes your annual family income? |
|
| Under $15,000 |
|
| $15,000 to $19,000 |
|
| $20,000 to $29,000 |
|
| $30,000 to $39,000 |
|
| $40,000 to $49,000 |
|
| $50,000 to $74,000 |
|
| $75,000 to $99,000 |
|
| $100,000 to $149,000 |
|
| $150,000 to $199,000 |
|
| $200,000 to $249,000 |
|
| $250,000 and over |
|
| |
|
| Education Level |
|
| Completed High School |
|
| Trade Degree / Certificate |
|
| Some College Study |
|
| 4-year College Degree |
|
| Some Graduate Study |
|
| Graduate Degree |
|
| |
|
| Do you currently own or rent your home? |
Own
Rent |
| |
|
| What is the length of stay at your current residence? |
|
| Within 1 month |
|
| Within 3 months |
|
| Within 6 months |
|
| Within 1 year |
|
| Within 5 years |
|
| 5 years or more |
|
| |
|
| Which cuisines are typically prepared by your household? |
Check all that apply |
| Southwest |
|
| Southern |
|
| Californian |
|
| Caribbean |
|
| New England |
|
| Hawaiian |
|
| Midwest |
|
| Mediterranean |
|
| Middle Eastern |
|
| Mexican |
|
| Asian |
|
| Vegan or Vegetarian |
|
| Italian |
|
| |
|
| Which of the following do you use for shopping? |
Check all that apply |
| Internet |
|
| Catalog / Mail |
|
| TV Shopping |
|
| Specialty Store |
|
| Department Store |
|
| Airline Magazine |
|
| Big Box Retailer |
|
| Other: |
|
| |
|
| Which of the following apply to your household? |
Check all that apply |
| Have a dog |
|
| Have a cat |
|
| Have other pets |
|
| Donate to charitable causes |
|
| Watch TV |
|
| Own a computer |
|
| Surf the Internet |
|
| Own a cellular phone |
|
| |
|
| To help us understand our customers' lifestyles, please mark any interests that you or your spouse participate in regularly. |
Check all that apply |
| 1. Computer or console games |
|
| 2. Camping or hiking |
|
| 3. Physical fitness or exercise |
|
| 4. Snow skiing |
|
| 5. Tennis |
|
| 6. Golf |
|
| 7. Basketball |
|
| 8. Bicycling |
|
| 9. Running / Jogging |
|
| 10. Fishing |
|
| 11. Hunting or shooting |
|
| 12. Powerboating |
|
| 13. Sailing |
|
| 14. Needlework or knitting |
|
| 15. Sewing |
|
| 16. Gardening |
|
| 17. Crafts |
|
| 18. Automotive work |
|
| 19. Electronics |
|
| 20. Listen to radio music |
|
| 21. Listen to talk radio |
|
| 22. Online forums or blogs |
|
| 23. Do-it-yourself home improvement |
|
| 24. Recreation vehicles (RV's) |
|
| 25. Records, tapes, CDs, or online music downloads |
|
| 26. Bible or devotional reading |
|
| 27. Health or natural foods |
|
| 28. Photography |
|
| 29. Cultural arts |
|
| 30. Fashion clothing |
|
| 31. Art or antique collecting |
|
| 32. Foreign travel |
|
| 33. Gourmet cooking or fine foods |
|
| 34. Collectibles |
|
| 35. Our national heritage |
|
| 36. Real estate investments |
|
| 37. Stocks or bond investments |
|
| 38. Casino gambling |
|
| 39. Wildlife or environmental issues |
|
| 40. Science or technology |
|
| 41. Computers and computer programming |
|
| |
|
| Using the numbers above, please list the top three interests that are most important to you. |
First
Second
Third |
| |
|
|
|
| |
|
