Survey Form

ABC Electronics

Survey Form

If you are interested in purchasing one or more of our products, before ordering please complete some or all of the following survey for our marketing department.  Answering any question is optional, and all information will be kept strictly confidential.  Thank you very much for your time!

1. What is your name?
   
   
2. What is your date of birth?
   

   Month: JanuaryFebruaryMarchApril MayJuneJulyAugust SeptemberOctoberNovemberDecember

   Date: 123456 789101112 131415161718 192021222324 252627282930 31

   Year:

   
   
3. What is your mailing address (if you would like to have a hard copy of our catalog sent to you)?
   Number/P.O. Box/Route: Street/Avenue/Road: City: State/Zip:
   
4. What is your email address?
   
   
5. Have you viewed our online product catalog?
   Yes No
   
6. If so, what product(s), besides the one you are ordering, might you be interested in purchasing in the future? (Check all that apply.)
   VCR
   Big Screen TV
   Audio Equipment
   Video Equipment
   Camera Equipment
   Other
   
7. Do you have any questions, comments or suggestions before proceeding to the Order Form?
   Your Input:
   
   

Again, thank you...we appreciate the information.  Please proceed now to the Order Form.