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Your answers to the following questions are appreciated.

1. This product was purchased from:

3. How did you learn about this product:

Home Center

Other (

)

Hardware/Lumber Store

Tool Distributor

Industrial Supply

Construction Supply

2. Use of the product is intended for:

Construction Trade

Industrial Maintenance

Home Maintenance

Hobby

Other ()

Magazine

From Dealer

Newspaper

Store Display

Catalog

4. Most favored points are:

Design

Features

Size

Price

Makita Brand

Radio

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Other ()

Repair Service

Durability

Power

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5. Any comments:

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DATE PURCHASED

 

 

 

 

 

MODEL NO.

 

 

MONTH

DAY

YEAR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SERIAL NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATUS

 

SEX

INTL. LAST NAME / COMPANY NAME

 

 

Married Single

M

F

STREET ADRESS

CITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AREA

 

 

 

 

STATE

 

 

 

 

 

ZIP CODE

 

PHONE

 

 

CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AGE:

 

 

 

Under 19

 

 

20-29

 

 

 

30-39

 

40-49

 

50-60

 

 

Over 60

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BE SURE TO COMPLETE THE CUSTOMER’S PORTION OF THIS FORM AND RETAIN FOR YOUR RECORDS.

Please return this portion by facsimile or mail.

14Facsimile No: (714) 522-8133

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