1. Mr.  Mrs.  Ms.  Mss 
*Name / Nom:
 In.:
 *Last Name / Prenom:
Address / Adresse:
 Apartment #:
City / Ville:
State / Province:
 Zip Code:
Daytime Phone Number:
2. *Email:
3. * Purchase Price:
$ 		4. * Date of Purchase (MM/DD/YY):
5. *Model Number:
 6. * Serial Number: (Numbers Only)
7. Store Location:
8. What factors most influenced this purchase? (check up to 3)
Received as a gift Recom. of Friend Advertising
Style/Appearance Recom. of Salesperson Ease of Operation
Portability Product Features Power of Product
Price Previously owned Pressure washer Size/Weight
Technical Apps.     
9. What activities do you participate in regularly?
Camping/Fishing Automotive Work 4-Wheeling
Fishing Automotive Repair Motorcycling
Hunting/Shooting Home Improvement  
Boating/Sailing CB Radio  
Recreational Vehicle    
10. What other brands did you consider before buying this product?
Air Tool Company Campbell Hausfeld Honda
Excell Generac Karcher
Northern Pro MiTM None
Northern Hydraulics North Star Other
Sears/Craftsman Devilbiss  
11. Which of the following best describe this purchase: (check all that apply)
1. First Purchase
  
2. Replacement: specify brand
3. Addition to: specify brand
12. What are the primary uses for your PowerWasher Product?
Home Improvement Projects Cleaning Recreational Vehicles
Automobile Maintenance Other
Additional Explaination:
13. Would you be interested in a catalog of other PowerWasher Products?
Yes No
14. What is your date of birth?
Year:Month:Day:
15. Marital Status: Single Married
16. Which best describes your family income?
Under $15,000 $50,000-$74,999
$15,000-$24,999 $75,000-$99,999
$25,000-$34,999 $100,000-$149,999
$35,000-$49,999 Over $150,000
17. Education?
High School Completed College
Some College Graduate School
18. Including yourself, what is the total number of people living in your household?
Male: Ages:
Female: Ages:
19. In the last six (6) Months have you or others in your household:
Purchased clothes through the mail? Traveled on Vacation? Purchased cassettes/CDs?
Purchased gifts through the mail? Purchased a PC or PC software Donated to wildlife / environmental causes?
Worked in your garden? Purchased two or more books?

Donated to charities?
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