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Mr. Mrs. Ms. Miss Customer ID from Invoice
Name:
Address: Apt. #:
City: State: ZIP:
Phone number: -
E-Mail address:
Is this your primary address? Yes No
Place of purchase:
Date of purchase:
Purchaser date of birth:
Gender: Male Female
Marital status: Married Single
Including yourself, total number of people living in your household: (Examples: 01, 02, 03 …)
Would you like to receive additional information on healthy lifestyle products? Yes No
Which best describes your family income:
Under $15,000 $25,000 – $34,999 $50,000 – $74,999 $100,000 – $149,999
$15,000 – $24,999 $35,000 – $49,999 $75,000 – $99,999 Over $150,000
What other types of exercise equipment do you own?
Did you receive this item as a gift? Yes No
Name of original purchaser:
Original purchaser customer ID number:
© 2006, Nautilus Inc. All Rights Reserved. 16400 SE Nautilus Drive, Vancouver, WA 98683. Bowflex, and SelectTech logos are either registered trademarks or trademarks of Nautilus Inc. 17241 Rev AA (03/04) Nautilus Inc.
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