Please take a moment to fill out this form so we can notify you of any changes or updates on the product you purchased. Mr.  Ms. Your Name (First,Last): Address: City: State: Country: Zip Code: Year of Birth: Phone Number: E-Mail: Occupation Professional Tradesman Retired Technical Student Homemaker Self Employed Other: Annual Income Under $19,999 $40,000-$49,999 $70,000-$124,999 $20.000-$29,999 $50,000-$59,999 Over $125,000 $30.000-$39,999 $60,000-$69,999   Model Number of the PIAA Product You Purchased: Where Was This Product Purchased? Nameof Store: StreetAddress: City: State: Zip Code: Phone Number: What Type of Store Was This Product Purchased? Specialty Automotive/ Domestic Car Audio Specialty Automotive/ Import General Auto Parts Light Truck/ 4x4 Accessory Mail Order/ Catalog On What Type of Vehicle Was This Product Installed? Car Other: SUV   Pickup Truck Make: Motorcycle Model: Mini Van Year: What is the Primary Use of This Vehicle? Business Sanctioned Racing Recreation General Transportation Other How Did you First Become Aware of This Product? Advice from friend Radio Newspaper ad Advice from experts Catalog Sales clerk Vehicle dealer TV ad Magazine ad Magazine article Retail ad Other What Were the Most Important Factors That Influenced Your Decision to Purchase This Product? (check all that apply please) Experience with other brands Safety Previous experience with PIAA Special features Salesperson's recommendation Ease of installation Friends recommendation Warranty Quality/ design PIAA reputation Immediate availability Quality/ durability Value for the price Lighting performance Other Who Did (or will do) Most of the Work to Install This Product? Self Friend/ relative Professional installer- cost Other What Other Brands did You Consider? PIAA only Hella KC Other Whichof These Following Activities do You Participate In? Hunting, fishing, camping Off-Roading Automotive sports events Other Is There Anything Else You Would Like to Tell PIAA About Their Products or Service?

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