Beyond Seven - Free Sample Request Form

Please complete the following survey to receive a free sample of Beyond Seven Condoms in 8 - 10 weeks. The free sample will be sent in a discreet package. Only one sample per household. If you have already received an offer from Beyond Seven, you may not be eligible. Offer valid only to persons 18 years or older and live in the United States. Void where restiricted or taxed. Offer good while supplies last.

Questions:

* 1. Have you ever used, heard of, or seen Beyond Seven condoms?

yes
no

* 2. Which brand of condoms do you currently purchase/use? (Check all that apply)

*3. How long have you been using your current preferred brand of condoms? (Select One)

1 - 6 months
6 - 12 months
1 - 2 years
3 - 5 years
5+ years

*4. What feature(s) in a condom are important to you? (Check all that apply)

*5. What is your marital status? (Select One)

Single
Married/Engaged
Divorced
Other
Prefer not to answer

*6. When you have intercourse with your partner, do you: (Select One)

Always use condoms
Sometimes use condoms
Rarely use condoms
Never use condoms
Prefer not to answer

*7. In a typical week, how many condoms do you use? (Select One)

7 or more a week
4 - 6 a week
1 - 3 a week
Less than one a week
None
Prefer not to answer

*8. Which of our products would you be most interested in? (Check all that apply)

Beyond Seven (Lightly Lubricated, Ultra Thin, Blue Tinted)
Beyond Seven Plus (Spermicidally Lubricated, Ultra Thin, Blue Tinted)
Beyond Seven Studded (Studded texture for stimulation, lightly lubricated, blue tinted)
Beyond Seven Aloe (With ALOE-VERA Lubricant, Ultra Thin, Green Tinted)
I Do Not Know.

*9. How did you hear about Beyond Seven condoms? (Check all that apply)

*10. Where do you typically purchase condoms? (Check all that apply)

Drug Store / Pharmacy
Grocery Store / Supermarket
Mass Merchandiser / Discount Stores
Convenience Stores
Online / Catalogue

Free Supply
Speciality Shop
Others
I do not purchase condoms.

*11. In which of the following stores have you shopped in the past 1 month?
(Check all that apply)

*12. How old are you? (Select One)

18-24
25-34
35-44
45-54
55-64
65 or above

* 13. What is your gender?

Male
Female

*14. Select one of the following that best describes your ethnic background:
(Select One)

African American / Black
American Indian or Alaskan Native
Asian, Asian American, Pacific Islander or Indian Subcontinent
Hispanic
Caucasian / White
Some other ethnic background
Prefer not to answer

*15. Select one of the following that best describes your household income:
(Select One)

Less than $20,000
$20,000 - $39,999
$40,000 - $59,999
$60,000 - $79,999
$80,000 - $99,999
more than $100,000
Prefer not to answer

* 16. Would you like to receive future correspondence from Okamoto?

Yes
No

*First Name
*Last Name
*Address 1
Address 2
*City
*State
*Zip Code
Phone Number
*Email Address
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