My3ia USA, Inc. IMPORTANT!
   
Please complete and return within 30 days of the initial purchase!
Thank you for choosing a My3ia USA, Inc. product! Please fill out and complete
this form to register your purchase!
The information on the form enables us to serve you better
with products and promotions developed to meet your needs and interests.
Please take a moment right now to fill it out.
  1 Mr. Mrs. Ms. Miss
  First Name Initial Last Name
  Street Apt. No.
  City State Zip Code
  E-mail
  2. Telephone number (optional)
  3. Date of purchase: Month Day Year    
  4. Product purchased: MP3 Player Flash Drive Wireless Lan Remote Presenter Model number
  5. Name of store where purchased:
     Name City State
  6. Please select the 2 most important factors that influenced your desire to purchase this product:
  1. Name brand 4. Warranty 7. Special incentive
  2. Advertising 5. Gift 6. Price
  3.Product feature 8. In-store display 9. Salesperson's recommendation
  7. Which group describes your age bracket?
  1. 0 to 20 3. 31 to 40 5. 51 to 60
  2. 21 to 30 4, 41 to 50 6. Over 60
  8. Which group describes your annually family income?
  1. Under $24,999 4. $55,000 to $69,999 7. Over $100,000
  2. $25,000 to $39,999 5. $70,000 to 84,999    
  3. $40,000 to $54,999 6. $85,000 to 99,000    
 

    Thanks for taking the time to fill out this questionnaire. Your answers will be used for market research studies and reports and to provide you with information about our products and services and with information about exciting opportunities from other companies. We will also share your information with the company that processes these registrations. Competition of this form will allow them to provide you with important mailing and special offers from a number of fine companies whose products and services relate directly to the specific interests and other information indicated above. Through this selective program, you will be able to obtain more information about activities in which you are involved and less about those in which you are not. Please check here if for some reason you would prefer not to provide and participate in this opportunity.

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