DATE PURCHASED
MODEL NO.
MONTH DAY YEAR
SERIAL NO.
STATUS SEX
INTL. LAST NAME/COMPANY NAME Married Single M F
STREET ADDRESS
CITY
AREA CODE
STATE ZIP CODE PHONE
AGE: Under 19 20-29 30-39 40-49 50-59 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.
Facsimile Number (714) 522-8133
Page 19
MAIL THIS PORTION
Your answers to the following questions are appreciated.
1. This product was purchased from:
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 ( )
5. Any comments:
3. How did you learn about this product:
Magazine Radio
From Dealer Exhibition
Newspaper From Friend
Store Display Previous Usage
Catalog Other ( )
4. Most favored points are:
Design Repair Service
Features Durability
Size Power
Price Other ( )
Makita Brand
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