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YOUR COMPANY LOGO OR SURVEY NAME HERE
Q.1: When did you first start using (product/service)?
Less than 1 year ago
1 year to less than 3 yrs ago
3 to less than 5 yrs ago
5 to less than 10 yrs ago
10 yrs ago or more
Not certain/cannot recall
Q.2: What were your primary reasons for choosing (product/service)?
Q.3: How satisfied are you overall with (product/service)?
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
Can't say
Q.4: Which of the following is your preferred method for receiving information from us about (product/service)?
Telephone
Email
Regular mail
Fax
At retail store
Other (specify):
Q.5: What suggestions would you make for improving (product/service)?
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