CONSUMER INFORMATION ( * = Required Fields)
Last Name * First Name *
Address * City/Town *
Province * Postal Code *
Phone Number *   -    -   Email *
Purchaser Marital Status
PRODUCT INFORMATION ( * = Required Fields)
Product * Model Number *
Store of Purchase * Date of Purchase *
(DD/MM/YY)		   /    /  
Serial Number UPC (Barcode) Number *
Including yourself, how many people live in your household?
(Please enter in number, not words)		 Children (18 & younger)
Adults
Education (check all that apply)
Some highschool College/University degree
Completed highschool Graduate degree
For your permanent residence, do you
Yes! I want to receive offers or communications about Super Electric product lines: Super™, Weatherworks®, Bellagio, Clairtone® and/or Airworks® products via email.
HELP US SERVE YOU BETTER
1. What was the reason for the purchase of this appliance (check one)
Replacing old appliance Upgrading features
Upgrading performance Upgrading design
Completely new use
2. What appliances would you likely buy in the next 1-6 months? (check all that apply)
Heater Fan
Coffee maker Refrigerator
Personal Appliances Dehumidifier
Wine Cooler Air Purifier
Humidifier Other
3. Please check the two (2) most important reasons influencing this decision
Received as gift Value for price
Prior experience
with brand 		Ease of operation
Completely new use Style/Appearance
Special Offer Quality/Durability
Recommendation of friend/family
4.A) If you bought this product yourself, did you plan to purchase this type of product before going to the store?
Yes No
B) If yes, Did you plan to purchase as specific brand?
Yes No
C) If yes, Did you plan to purchase Super, Weatherworks,  Bellagio, Clairtone or Airworks?
Yes No
5. Rank the following factors when purchasing appliances (check one)
1- Not important  3- Average  5 - Very important
1 2 3 4 5
Innovation
Functionality
Style
Brand
Price
Reputation
6. How did you first become aware of this product
Received as gift TV shopping program
Newspaper flyer In-Store demo
Seen product in store Recommendation of
friend/family
Consumer magazine article Other
7. What describes your annual family income (CDN $)
Under $49 999 $50 000-$74 999
$75 000 - $124 999 $125 000 Plus
8. Which credit cards do you use regularly?
American Express, Diner Club MasterCard, Visa, Discover
Do not use credit cards Department Store, Oil Company, Etc.
    
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