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Have you ever ordered [PRODUCT] from [COMPANY]?
 
Yes
 
No
 
 
 
Overall, how would you rate [COMPANY]?
 
Excellent
 
Good
 
Average
 
Poor
 
Terrible
 
 
 
How satisfied are you with your service from [COMPANY]?
 
Extremely satisfied
 
Very satisfied
 
Neutral
 
Very dissatisfied
 
Extremely dissatisfied
 
 
 
Would you recommend [COMPANY] to a friend?
 
Yes
 
No
 
 
 
If no, why not?
   
 
 
 
For your NEXT [PRODUCT] purchase, how likely are you to purchase from [COMPANY]?
 
Very likely
 
Somewhat likely
 
Not sure
 
Somewhat unlikely
 
Very unlikely
 
 
 
Which of the following modes did you use to place the LAST order for [PRODUCT]?
 
Mail order
 
Internet
 
Over the phone
 
Fax
 
Other
 
 
 
 
What are the THREE main reasons you didn't purchase [PRODUCT] from [COMPANY]?
   
 
 
 
If you could change something about [COMPANY] what would it be?
   
 
 
 
Are there any other comments you have for [COMPANY]?