*Required Fields

1. Name & Address:
Title:
-- Please Select -- Mr. Mrs. Ms. Miss
*First Name:
Initial:
*Last Name:
*Street:
Apt. No.:
*City:
*State/Province:
-- Please Select -- AA AB AE AK AL AP AR AS AZ BC CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MP MS MT NB NC ND NE NH NJ NL NM NS NT NU NV NY OH OK ON OR PA PE PR QC RI SC SD SK TN TX UM UT VA VI VT WA WI WV WY YT
*Zip/Postal Code:
*E-mail Address:
Phone Number (Not Required) :
2. Age:
a. 18-25
b. 26-35
c. 36-45
d. 46-55
e. 56-65
f. 66 and up
3. Marital Status:
Married
Single
4. *Date of Purchase:
(MM/DD/YYYY)
5. *Model Number:
(located on product box)
-- Please Select -- BB-SSC10-SCALE
6. *Lot Number:
(Located on the bottom or side of the product. )
7. *Store Where Purchased:
8. Receipt:
(If you have a receipt available, please use the form below to upload. A physical copy must also be submitted.)

9. Type of Store Where Purchased:
a. Received as a Gift
b. Specialty Store
c. Online / Internet
d. Television / Catalog
e. Department Store
f. Warehouse Club
g. Grocery / Supermarket
h. Military Exchange
i. Other
10. How did you first become aware of this product?:
a. Received as a gift
b. Online/Internet
c. Magazine Article/TV Feature
d. Friends/Family Recommendation
e. Store Display/Sales Person/Store Advertisement
f. In-Store Demo
g. Advertisement (TV, Internet, Radio, etc.)
h. TV Shopping Program
i. Catalog
j. Past Experience with Zojirushi
k. Other
11. What factors most influenced your purchase?:
(Please select all that applies)
a. Received as a Gift
b. Brand Reputation
c. Product Reputation
d. Product Features
e. Product Packaging
f. Friends/Family Recommendation
g. Value for Price
h. Design/Appearance
i. Store Display
j. Quality/Durability
k. Special Offer
l. Recommendation of Salesperson
m. Zojirushi Website
n. Zojirushi Advertisement
o. Retailer Website
p. Retailer Advertisement
q. Online Reviews
r. Saw in Magazine/Catalog
s. Prior Experience with Zojirushi
12. This product is:
a. Your first product of this type
b. A replacement for a Zojirushi product of this type
c. A replacement for another brand
d. An additional purchase
13. What other brands did you consider?:
14. Which of the following products do you:
Currently Own
Intend to Buy
a. Drip Coffee Maker a.
b. Single Serve Coffee Maker b.
c. Espresso Maker c.
d. Coffee Grinder d.
e. Toaster Oven/Toaster e.
f. Slow Cooker f.
g. Food Processor g.
h. Kitchen Scale h.
i. Hot Water Pot/Boiler i.
j. Electric Kettle j.
k. Hand Mixer k.
l. Stand Mixer l.
m. Breadmaker m.
n. Rice Cooker n.
o. Electric Griddle o.
p. Electric Indoor Grill p.
q. Electric Grill (Folding-Type, Panini Press) q.
r. Juicer r.
s. Blender s.
t. Immersion Blender t.
u. Steamer u.
15. Ethnicity:
Caucasian/White
Asian/Asian American
Asian Indian Chinese Taiwanese Filipino Japanese Korean Vietnamese Other Asian
African American
Hispanic/Hispanic American
Central American or South American Cuban Dominican Mexican, Mexican American, Chicano Other Spanish or Latino Puerto Rican
American Indian or Alaskan Native
Native Hawaiian or Other Pacific Islander
Native Hawaiian Guamian or Chamorro Samoan Other Pacific Islander Other Asian
Other
16. You are:
a. A professional
b. Self employed
c. A student
d. In the military
e. Retired
f. A homemaker
g. Other
17. Annual Household Income:
a. Under $20,000
c. $20,000 - $39,999
e. $40,000 - $59,999
g. $60,000 - $79,999
h. $80,000 - $99,999
i. $100,000 - $149,999
j. $150,000 and over
18. Any Comments?: