REQUIRED INFORMATION:
Product Purchased:
Mini MagliteŽ 2-Cell AAA Flashlight
Mini MagliteŽ 2-Cell AA Flashlight
MagliteŽ C-Cell Flashlight
MagliteŽ D-Cell Flashlight
MagliteŽ Rechargeable Flashlight System(tm)
MagliteŽ SolitaireŽ Single-Cell AAA Flashlight
Mini Maglite® LED AA-Cell Flashlight
Maglite® LED D-Cell Flashlight
Serial Number
(excludes SolitaireŽ, Mini MagliteŽ AA, AAA)
Date Purchased
01
02
03
04
05
06
07
08
09
10
11
12
/
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
/
2005
2006
2007
2008
2009
2010
2011
2012
First Name:
M.I.:
Last Name:
Company:
Address:
City/Locality:
State/Province:
Country:
Zip/Postal Code:
Email:
Phone Number:
Fax Number:
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OPTIONAL INFORMATION:
Household Income:
Under 25,000
25,001 - 50,000
50,001 - 100,000
Over 100,000
Education:
High School
College
Completed College
Graduate Degree
Post-Graduate Degree
Reason For Purchase:
Personal Use
Emergency Use
Purchased As A Gift. Please Specify Occasion:
Christmas
Father's Day
Graduation
Mother's Day
Birthday
Other
Received As A Gift. Please Specify Occasion:
Christmas
Father's Day
Graduation
Mother's Day
Birthday
Other
Intended Use:
Law Enforcement
Utilities
Fire
EMS
Rescue
Industrial / Commercial
Safety / Security
Pest Control
Electrical / HVAC
Home - Recreational
Auto - Recreational
Home - Emergency
Auto - Emergency
Camping / Hiking / Backpacking
Hunting / Fishing
Primary Residence:
Own A Home
Rent A Home
Own An Apt/Condo
Rent An Apt/Condo
Age:
0-18
19-25
26-40
40-60
Over 60
Occupation:
Public Safety (Police / Fire)
Military
Business Owner/Partner
Computer Services
Craftsman/Tradesman
Doctor/Dentist
Farmer
Homemaker
In Home Business
Lawyer
Machine Operator / Laborer
Manager
Mechanic
Nurse / Medical
Office / Clerical
Professional
Retail / Storefront
Retired
Sales / Marketing
Student
Teacher/Educator K-12
Security
Machinist
Engineer
Other
Hobbies / Activities:
Automotive Work
Reading
Camping / Hiking
Crafts
Cycling
Do-It-Yourself
Travel
Fishing
Fitness / Exercise
Gardening
Golf / Tennis
Hunting / Shooting
Motorcycles
Photography
Snow Skiing / Snow Boarding
Scuba Diving / Snorkeling
Flying
Running / Jogging
Personal Computing
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Other
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