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Click here to Contact Us! 11035 Technology Place Suite 100 San Diego, CA 92127 1-888-9-SEPHRA (1-888-973-7472) Sephra Product Registration Thank you for registering! With the information you provide, we will be able to notify you of any substantive issues that arise concerning your fountain. Completing this form in its entirety will allow us to serve you better should any warranty issues arise. Title Mr. Mrs. Ms. First Name Middle Name Last Name Street Address   City/Town State/Province Postal Code Country E-mail Address 2. Your Date of Birth: Month Year January February March April May June July August September October November December 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 3. Marital Status: Married   Single 4. Date of Purchase: Month Day Year January February March April May June July August September October November December 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2008 2007 2006 2005 5. Model: Sephra Signature Fondue Fountain Sephra Elite Fondue Fountain Sephra Classic Fondue Fountain Sephra Select Chocolate Fountain 6. Name of store where purchased: 7. How did you first become aware of this product? Received as a gift TV Commercial Advertisement Recommendation of Friend/Family In-store Demo Saw in Store Internet TV Shopping Program Magazine Article Other: 8. Check the two (2) most important reasons influencing this purchase. Received as a gift   Value for Price Special Offer Recommendation of Friend/Family Ease of Operation Recommendation of Salesperson Product Features Saw in Magazine/Catalog Style/Appearance Only Brand Available Quality/Durability Saw on TV 9. Did you: Buy this product yourself? Request this product as a gift? Receive this product as a surprise gift? 10. If you bought this product for yourself or requested it as a gift, did you... Plan to purchase this type of product before going to the store? Yes No If yes, did you plan to purchase a specific brand? Yes No If yes, was the brand Sephra? Yes No 11. 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 Male Female Age: yrs. Male Female Age: yrs. Male Female Age: yrs. Male Female Age: yrs. Male Female Age: yrs. Male Female Age: yrs. Male Female Age: yrs. 12a. Occupation (check all that apply):     You   Spouse Professional/Technical     Upper Management/Executive     Middle Management     Sales/Marketing     Clerical/Service Worker     Tradesman/Machine Operator/Laborer     12b. Are you or your spouse (check all that apply)...     You   Spouse A Homemaker?     Retired?     A Student?     Self Employed/Business Owner?     Working from a Home Office?     In the Military?     A Veteran?     13. What is your annual family income? Under $15,000   $80,000 - $89,999 $15,000 - $19,999   $90,000 - $99,999 $20,000 - $29,999   $100,000 - $124,999 $30,000 - $39,999   $125,000 - $149,999 $40,000 - $49,999   $150,000 - $174,999 $50,000 - $59,999   $175,000 - $199,999 $60,000 - $69,999   $200,000 & over $70,000 - $79,999     14. Level of Education: High School College Graduate School 15. For your primary residence, do you... Own? Rent? Please review all information for accuracy.

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