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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.