Simmons® - Warranty Registration

Personal Data Collection Statement:
All personal data provided below are subject to the willingness of customers. Information collected by Shanghai Simmons Bedding & Furniture Sales Ltd is exclusively for the puposes of warranty registration, marketing analysis and promotions. All information collected will be kept strictly confidential.

Fields marked with * are required.

A. Customer and Purchase Information

1. Name: *

(Mr./Ms.) (in BLOCK letters)

2. Home Address:*

3. Home Tel. No.:*

4. Mobile/Office No.:*

5. Email Address:*

6. Delivery Date:*

Day Month Year

7. Invoice No.:*

Product Serial No.:*

8. Merchant:

9. Product:*

Mattress

Box Spring / Foundation

10. Mattress Model:

Buchanan	Corbridge	Connor
Rozelle	Custom Royal® Deluxe	Callisburg
Merriam Euro Top	Merriam	BackCare®3
Others (Please specify):

11. Size:*

B. Customer survey

12. Gender:

Male

Female

13. Age Group:

<=25

26-35

36-45

=>46

14. Education:

Primary

Secondary

Post-secondary/College

University

15. Occupation:

Owner/Sole Proprietor	Professional	Manager/Senior Executive
Technician/Engineer	Clerk	Blue Collar
Housewife	Retired
Others (Please specify):

16. Monthly Household
Income:

<=RMB20,000	RMB20,001-30,000	RMB30,001-40,000
RMB40,001-50,000	=>RMB50,001

17. Marital Status:

Single	Single w/ child(ren)
Married, w/o child	Married, w/ child(ren)

18. Reason(s) for the
purchase

New Home	Getting Married
Upgrade sleep quality	Replace old Simmons® product
Replace non-Simmons® product (Please specify brand name):

19. Why choose
       Simmons®?
      (Can choose more than
      one option)

Brand reputation	Comfort
Product quality & craftsmanship	Promise of uninterrupted sleep
Recommendation from by relatives/friends	Promotion
Convincing sales consultants	Good experience w/ Simmons®
Others (Please specify):

20. Warranty Card No.*

Customer Service Hotline: (86 21) 6248 2233