Product Registration

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  1. Title:   Mr.    Mrs.    Ms.    Miss
    First Name:     Initial:      Last Name:
    Street:      Apartment
         Number:
    City:      State/Province:
    ZIP Code:
    E-mail Address:

  2. Your date of birth: Month Year

  3. Marital Status: Married Single


  4. Which Everpure product did you purchase?
    ProSeries 1500
    ProSeries 2500
    ProSeries 3500
    CTS-54
    S-54
    H-50
    H-54
    S-104
    S-100 Dual
    H-100 Dual
    H-104
    S-200
    H-200
    H-201
    H-300
    H-1200
    QC4-THM
    QC4-VOC
    Water Purification
            System for RVs & Boats
    ROM II System
    ROM III System
    Other:

  5. Price paid (excluding sales tax): $ .00

  6. Name and location of store where purchased:
    City:  State:

  7. Date of Installation: Month Day Year


  8. Which of the following will be connected to this product? (check all that apply)
    Filtered Water Faucet
    Regular Kitchen Water Faucet
    Refrigerator Ice Maker
    Refrigerator Chilled Water Dispenser
    Undercounter Water Chiller
    Instant Hot Water Dispenser
    Undercounter Ice Maker
    Plumbed-In Coffee Maker
    Wet Bar
    Other


  9. What influenced you most to buy a filter at this time? (check only 1)
    Concern About the Safety of Your Water
    Local Alerts to Water Supply Problems
    Concern About Lead in Your Water
    Concern About Chemical Contaminates
    Concern About Cysts Such as ÒCryptoÓ
    Medical/Health Reasons
    Baby in Home
    Taste/Odor of Water
    Dirt/Discoloration of Water
    Other


  10. Why did you choose an Everpure water filter over other brands available? (check up to 3)
    Received as a Gift
    Friend/Relative Recommendation
    Salesperson Recommendation
    Brand Reputation
    NSF Certification
    Ease of Installation
    Ease of Cartridge Change
    Price
    Other


  11. Where will this Everpure product be used?
    Primary Residence
    Summer Home or Cottage
    Trailer, Fifth-Wheel or Motor Home
    Pleasure Boat with Galley


  12. Which of the following do you own? (check all that apply)
    Summer Home or Cottage
    Trailer, Fifth-Wheel or Motor Home
    Pleasure Boat with Galley


  13. Who installed (or will install) this product?
    Self
    Friend/Relative
    Professional Installer
    Other


  14. How easy or difficult did you find the installation of this product?
    Very Easy
    Relatively Easy
    Somewhat Difficult
    Very Difficult


  15. Which of the following do you currently own? (check all that apply)
    Water Softener/Conditioner
    Chlorinator
    Whole House Filter
    Iron Filter
    Filter Pitcher
    Faucet Mount Filter
    Countertop Filter
    Refrigerator Filter
    Shower Filter


  16. A. Is this purchase replacing any of the items listed in Question 14?
    Yes     No
    B. If "Yes", please indicate which item number:
    1.
    2.
    3.
    4.
    5.
    6.
    7.
    8.
    9.


  17. Please check all that apply to your household.
    Own a Compact Disc Player
    Subscribe to an Online/Internet Service
    Own an IBM or Compatible Computer
    Own an Apple/Macintosh Computer
    Own a CD-ROM


  18. Which group describes your annual family income?
    Under $15,000
    $15,000-$19,999
    $20,000-$29,999
    $30,000-$39,999
    $40,000-$49,999
    $50,000-$59,999
    $60,000-$74,999
    $75,000-$99,999
    $100,000-$124,999
    $125,000-$149,999
    $150,000-$174,999
    $175,000-$199,999
    $200,000-$249,999
    $250,000 & over


  19. Which of the following do you plan to do within the next 1-6 or 7-12 months? (check all that apply)
      1-6
    Months
    7-12
    Months
    Get Married
    Have a Baby
    Buy a House
    Remodel a Home
    Move to a New Residence
    Buy a Personal Computer
    Buy/Lease a New Vehicle
    Buy/Lease a Used Vehicle


  20. Not including yourself, what is the GENDER and AGE (in years) of children and other adults living in your household?
    No one else in household     Child under 1 year
    1.  Male   Female Age (in yrs):
    2.  Male   Female Age (in yrs):
    3.  Male   Female Age (in yrs):
    4.  Male   Female Age (in yrs):


  21. Which credit cards do you use regularly?
    American Express, Diners Club
    MasterCard, Visa, Discover
    Department Store, Oil Company, etc.
    Do not use credit cards


  22. To help us understand our customers' lifestyles, please indicate the interests and activities in which you or your spouse enjoy participating on a regular basis.

      Home Life 01. Grandchildren
    02. Home Workshop/Do-It-Yourself
    03. Home Video Recording

      Good Life 04. Attending Cultural/Arts Events
    05. Cruise Ship Vacations
    06. Foreign Travel
    07. Travel in USA

      Investing &
      Money
    08. Stocks/Bonds/Mutual Funds
    09. Entering Sweepstakes

      Sports, Fitness
      & Health
    10. Golf
    11. Physical Fitness/Exercise
    12. Health/Natural Foods

      Great Outdoors 13. Camping/Hiking
    14. Fishing
    15. Hunting/Shooting

      Hobbies &
      Interests
    16. Listen to Records/Tapes/CDs
    17. Avid Book Reading
    18. Bible/Devotional Reading
    19. Coin/Stamp Collecting
    20. Wildlife/Environmental Issues 
    21. Surf the Internet


  23. Using the numbers in the above list, please indicate your 3 most important activities:
           

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    To clear the form, press this button:

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