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  1. Name & Address:  
     
    * Title Mr.    Mrs.    Ms.    Miss
    * First Name Initial * Last Name
           
    * Street Apt. No. * City
    * State/Province * Zip/Postal Code
    * E-mail Address

    2. YES! I want to receive offers or communications from Wagner via e-mail.
     
  2. Your date of birth:
    3.  
  3. Marital Status: Married Single
    4.  
  4. Date of purchase: 
    5.  
  5. Kit name:
    6.  
  6. Name of store where purchased:
    7.  
  7. Price paid (excluding sales tax): $ .00
    8.  
  8.   A. Have you Faux Finished previously?
     
    Yes No

      B. If yes, what technique/s did you apply?
     
    Sponging
    Ragging
    Dragging/combing
    Color washing
    Marbleizing    		 Texture
    Clouding
    Border accents/Stenciling
    Other

    9.  
  9. What room in your house are you planning on painting?
     
    Kitchen
    Dining room
    Living room
    Foyer    		 Adult's Bedroom
    Kid's Bedroom
    Bathroom
    Family room
    10.  
  10. How did you find out about WallMagic?
     
    Friend/Family
    TV
    In-store signage
    In-store sales associate    		 Magazine
    Book
    Internet
    11.  
  11.   A. Were you aware of WallMagic prior to this purchase?
     
    Yes No

      B. If yes, what technique/s were you aware of?
     
    Sponging
    Ragging
    Dragging/combing
    Color washing
    Marbleizing    		 Texture
    Clouding
    Border accents/Stenciling
    Other

    12.  
  12. Which of these techniques are you most likely to apply in your home?
     
    Sponging
    Ragging
    Dragging/combing
    Color washing    		 Marbleizing
    Texture
    Clouding
     
  13. Not including yourself, what is the GENDER and AGE (in years) of children
    and other adults living in your household?
     
    No one else in household Child under 1 year
    1. Male Female Age (in yrs):
    2. Male Female Age (in yrs):
    3. Male Female Age (in yrs):
    4. Male Female Age (in yrs):
    14.  
  14. Occupation: (check all that apply)
     
      You Spouse
    Professional/Technical
    Upper Management/Executive
    Middle Management
    Sales/Marketing
    Clerical/Service Worker
    Tradesman/Machine Operator/Laborer
    15.  
  15. Are you or your spouse:  
     
      You Spouse
    A Homemaker?
    Retired?
    A Student?
    Self Employed/Business Owner?
    Working from a Home Office?
    In the Military?
    A Veteran?
    16.  
  16. Which group describes your annual family income?
     
    Under $15,000
    $15,000-$19,999
    $20,000-$29,999
    $30,000-$39,999
    $40,000-$49,999     		$50,000-$59,999
    $60,000-$74,999
    $75,000-$99,999
    $100,000-$124,999
    $125,000-$149,999     		$150,000-$174,999
    $175,000-$199,999
    $200,000-$249,999
    $250,000 & over
    17.  
  17. Level of education: (select highest level completed)
     
    Completed High School
    Completed College
    Completed Graduate School
    18.  
  18. Which credit cards do you use regularly?
     
    American Express, Diners Club
    MasterCard, Visa, Discover     		Department Store, Oil Company, etc.
    Do not use credit cards
    19.  
  19. For your primary residence, do you:
     
    Own? Rent?
    20.  
  20. How recently did you move into your current residence?
     
    Within 30 days
    Within 1-3 months
    Within 4-6 months     		7 to 12 months ago
    Have not moved in the last 12 months
    21.  
  21. Which of the following do you plan to do within the next 1-6 or 7-12 months?
    (select all that apply)
     
      1-6 Months 7-12 Months
    Buy/Lease a New Vehicle
    Buy/Lease a Used Vehicle
    22.  
  22. Please check all that apply to your household.
     
    Shop by Catalog/Mail
    Shop via the Internet
    Member of Frequent Flyer Program
    Donate to Charitable Causes
    Own a Compact Disc Player
    Have a Dog     		Have a Cat
    Own a Wireless/Cellular Phone
    Speak Spanish
    Own an Apple/Macintosh Computer
    Own a CD-ROM Drive
    23.  
  23. To help us understand our customers' lifestyles, please indicate the interests
    and activities in which you or your spouse enjoy participating on a regular basis.
     
    01. Bicycling
    02. Golf
    03. Physical Fitness/Exercise
    04. Running/Jogging
    05. Snow Skiing
    06. Tennis
    07. Camping/Hiking
    08. Fishing
    09. Hunting/Shooting
    10. Powerboating
    11. Sailing
    12. Grandchildren
    13. Needlework/Knitting
    14. Sewing
    15. Flower Gardening
    16. Vegetable Gardening
    17. Crafts
    18. Buy Prerecorded Videos
    19. Automotive Work
    20. Electronics
    21. Home Workshop/Do-It-Yourself
    22. Recreation Vehicles (RVs)
    23. Listen to Records/Tapes/CDs
    24. Avid Book Reading
    25. Bible/Devotional Reading
    26. Health/Natural Foods     		27. Photography
    28. Cultural/Arts Events
    29. Fashion Clothing
    30. Art/Antique Collecting
    31. Foreign Travel
    32. Cruise Ship Vacations
    33. Travel in USA
    34. Gourmet Cooking/Fine Foods
    35. Wines
    36. Stamp/Coin Collecting
    37. Collectibles
    38. Our Nation’s Heritage
    39. Real Estate Investments
    40. Stocks/Bond Investments
    41. Contests/Sweepstakes
    42. Casino Gambling
    43. Science Fiction
    44. Wildlife/Environmental Issues
    45. Dieting/Weight Control
    46. Science/New Technology
    47. Self-Improvement
    48. Walking for Health
    49. Watching Sports on TV
    50. Home Video Recording
    51. Moneymaking Opportunities
    24.  
  24. Using the numbers in the above list, please indicate your 3 most important activities:
     
           




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