Step 1 of 3

• First Name*
*Required Field
• Middle Initial
• Last Name*
*Required Field
• Address 1*
*Required Field
• Address 2
• City*
*Required Field
• Select State* -- -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
*Required Field
• Zip/Postal Code*
*Required Field
• Email*
*Invalid Email Address
• Confirm Email Address*
*Email addresses do not match
• Phone Number
• Date of Birth MONTH January February March April May June July August September October November December DAY 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 YEAR 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
• NEXT STEP

Step 2 of 3

• Date of Purchase January February March April May June July August September October November December DAY 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 YEAR 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
• Name of Retailer You Purchased From?
• City of Retailer You Purchased From?
• State of Retailer You Purchased From? -- -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• Simmons Brand Purchased* -- -- Beautyrest Recharge Beautyrest Recharge World Class Comforpedic Beautyrest TruEnergy Beautyrest Black Other
*Required Field
• Beautyrest Model Line Purchased* -- -- Classic Elite TruEnergy Other
*Required Field
• Size of Mattress -- -- Crib Twin Full Queen King Other
• Foundation Type Purchased -- -- Standard Low-profile NuFlex Foundation (Adjustable) None
• Price Paid
• NEXT STEP

Step 3 of 3

• • How satisfied are you with your mattress?*
    • Not at all satisfied
    • Not very satisfied
    • Somewhat satisfied
    • Very satisfied
    • Extremely satisfied
  *Required Field
• • How Likely Are You to Recommend a Beautyrest?*
    • Not at all likely
    • Not very likely
    • Somewhat likely
    • Very likely
    • Extremely likely
  *Required Field
• • When Shopping for a New Mattress, Where Did You Get Information? (Check All That Apply)*
    • Beautyrest Website
    • Retailer Website
    • Other Websites
    • Facebook
    • Twitter
    • YouTube
    • Online Search
    • Friends & Family
    • Doctor/Chiropractor
    • Newspaper
    • Magazine
    • TV Ads
    • Radio Ads
    • Sales People
    • Other
  *Required Field

Thank you for your time. Please hit SUBMIT to submit your responses.