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  1. Name & Address:  
     
    * Title Mr.    Mrs.    Ms.    Miss
    * First Name Initial * Last Name
           
    * Street Apt. No. * City
    * State/Province * Zip/Postal Code
    * E-mail Address
  2.  
  3. Your date of birth:
  4.  
  5. Marital status: Married Single
  6.  
  7. Date of purchase: 
  8.  
  9.   Model number: Serial number:
  Model number: Serial number:
  • Price paid for Water Heater: $ .00
  • If installed, what was the cost of installation? $ .00
  • Which of the following best describes this purchase?
  • What was the primary reason you chose to replace the unit?
  • Name of store where purchased:
  • Type of store where purchased:
  • If you shopped for any plumbers (not a retail store), how did you find them?
    (check all that apply)
    Yellow Pages© Book
    Manufacturer website dealer locator
    Local utility recommendation
    Yellow Pages© Internet
    Manufacturer 1-800 number
    Sticker on unit
    Consumer advocate website
    Friend/Family recommendation
    Previous experience with dealer
    Other internet directory
    Contractor acquaintance recommendation
    Other
  • Who installed the unit?
  • Which of the following best describes the types of units you considered?
  •  
  • What other brands did you consider?
     
    AO Smith
    American
    Bradford-White
    Bosch
    GE
    Hotpoint
    Kenmore
    Maytag
    Noritz
    Rheem
    Rinnai
    Ruud
    State
    Takagi
    Whirlpool
  •  
  • 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):
  •  
  • Occupation: (check all that apply)
     
      You Spouse
    Professional/Technical
    Upper Management/Executive
    Middle Management
    Sales/Marketing
    Clerical/Service Worker
    Tradesman/Machine Operator/Laborer
  •  
  • Are you or your spouse:  
     
      You Spouse
    A Homemaker?
    Retired?
    A Student?
    Self Employed/Business Owner?
    Working from a Home Office?
    In the Military?
    A Veteran?
  •  
  • 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
  •  
  • Level of education: (select highest level completed)
     
    Completed High School
    Completed College
    Completed Graduate School
  •  
  • Which credit cards do you use regularly?
     
    American Express, Diners Club
    MasterCard, Visa, Discover
    Department Store, Oil
          Company, etc.
    Do not use credit cards
  •  
  • For your primary residence, do you:
     
    Own? Rent?
  •  
  • Please tell us how many magazines your household:
     
      A.
    Subscribes to
    B. Purchases at
    Stores/Newsstands
    1-3 per month
    4+ per month
  •  
  • Which of the following do you plan to do within the
    next 6 or 12 months?

     
      1-6 Months 7-12 Months
    Buy/Lease a New Vehicle
    Buy/Lease a Used Vehicle
  •  
  • Please check all that apply to your household.
     
    Shop by Catalog/Mail
    Shop via the Internet
    Member of Frequent Flyer
          Program
    Donate to Charitable Causes
    Own a Compact Disc Player
    Have a Dog
    Have a Cat
    Own a Wireless/Cellular Phone
    Speak Spanish
    Own an Apple/Macintosh
          Computer
    Own a CD-ROM Drive
    Home Workshop/Do-It-Yourself
  •  
  • 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. Needlework/Knitting
    03. Sewing
    04. Flower Gardening
    05. Vegetable Gardening
    06. Crafts
    07. Automotive Work
    08. Photography
    09. Home Video Recording

    Good Life
    10. Cultural/Arts Events
    11. Fashion Clothing
    12. Foreign Travel
    13. Cruise Ship Vacations
    14. Travel in USA
    15. Gourmet Cooking/Fine Foods
    16. Wines
    17. Self-Improvement
    18. Watching Sports on TV
    19. NASCAR

    Investing & Money
    20. Real Estate Investments
    21. Stocks/Bond Investments
    22. Contests/Sweepstakes
    23. Casino Gambling
    24. Moneymaking Opportunities

    Sports, Fitness & Health
    25. Bicycling
    26. Golf
    27. Physical Fitness/Exercise
    28. Running/Jogging
    29. Snow Skiing
    30. Tennis
    31. Health/Natural Foods
    32. Dieting/Weight Control
    33. Walking for Health

    Great Outdoors
    34. Camping/Hiking
    35. Fishing
    36. Hunting/Shooting
    37. Powerboating
    38. Sailing
    39. Recreation Vehicles (RVs)
    40. Wildlife/Environmental Issues

    Hobbies & Interests
    41. Buy Prerecorded Videos/
             DVDs
    42. Listen to Records/Tapes/CDs
    43. Avid Book Reading
    44. Bible/Devotional Reading
    45. Art/Antiques Collecting
    46. Stamp/Coin Collecting
    47. Collectibles
    48. Our Nation’s Heritage
    49. Electronics
    50. Science Fiction
    51. Science/New Technology

  •  
  • Using the numbers in the above list, please indicate your 3 most important activities:
     
           
  •  
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    ©2005 Reliance Water Heaters
    Reliance Water Heaters reserves the right to make product changes
    or improvements at any time without notice.