3 – DEMOGRAPHIC INFORMATION

GENDER:

…MALE

…FEMALE

MARITAL STATUS:

…MARRIED

…SINGLE

DATE OF BIRTH:

/ /

MM DD YYYY

INCLUDING YOUR SELF, HOW MANY PEOPLE LIVE IN YOUR HOUSEHOLD?

NUMBER OF CHILDREN UNDER 18 LIVING IN YOUR HOUSEHOLD:

PRIMARY RESIDENCE:

…OWN

…RENT

EDUCATION

…SOME HIGH SCHOOL

…HIGH SCHOOL DIPLOMA

…COLLEGE DEGREE

…GRADUATE DEGREE

HOUSEHOLD INCOME

 

 

… LESS THAN $15,000

… $100,000 - $124,999

… $15,000 - $29,999

… $125,000

- $149,000

… $30,000 - $49,999

… $150,000

– $174,999

… $50,000 - $79,999

… $175,000

– $199,999

… $80,000 - $99,999

… $200,000

OR OVER

PRIMARY METHOD OF PURCHASING HOUSEHOLD ITEMS:

…IN-STORE

…ONLINE

…TV

…MAIL ORDER

TYPES OF CREDIT CARDS HELD BY HOUSEHOLD MEMBERS:

…VISA/MASTER CARD

…DISCOVER

…AMERICAN EXPRESS

…GAS/RETAIL

…OTHER

…NONE

HOUSEHOLD INTERESTS:

…HOME IMPROVEMENT

…AUTOMOTIVE WORK

…CAMPING

…OTHER:

_________________________________________

THANK YOU FOR REGISTERING YOUR PRODUCT. THE INFORMATION YOU PROVIDED MAY BE USED FOR MARKETING PURPOSES IN ORDER TO OFFER YOU VARIOUS PRODUCT INFORMATION AND OFFERS.

…CHECK HERE IF YOU DO NOT WISH TO BE CONTACTED ABOUT SPECIAL OFFERS. PLEASE RETURN THIS FORM TO THE FOLLOWING ADDRESS:

Northshore Power Systems, LLC

4425 N Port Washington Road

Suite 105

Milwaukee WI 53212-1082

PLEASE MAIL THIS FORM IN A SEALED ENVELOPE. DO NOT STAPLE.