Please provide the following contact information (all fields MUST be completed):

First Name
Last Name
E-mail Address
Street Address
Address (cont.)
City
State/Province
Zip Code
Country
Home Phone

Please provide the following product information:

Model
Serial Number
Date Purchased
Retailer Purchased From
Type of Store
City & State Where Purchased
Price Paid

Please take a moment to give us your answers to the following questions.
All responses are used solely for market research and held in strict confidence.

Do you own any other portable heaters?	Yes     No
If so, how many:
What brands:
Are you satisfied?	Yes     No
Please indicate your age group:	Select Group Under 25 25-34 35-44 45-54 55-64 64 or older

How do you intend to use your new heater?            Select One Emergency Heat Extra Heat Primary Heat
Where did you hear about this heater?                       Select One Price Store Display Salesperson Recommendation Radio Ad Newspaper Ad Other (please specify)
If other please specify	What is your occupation?
What is your income bracket?	Select One Under $15,000 $15-30,000 $30-45,000 $45-$60,000 Over $60,000
Do you own or rent your home?	Own     Rent
Would you recommend this heater to a friend?	Yes      No