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Middle Initial
Last Name
Address
Address (cont'd.)
City
State
State
Alabama
Alaska
American Samoa
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California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
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Tennessee
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Utah
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Virginia
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Zip
Email
Email
Phone Number
Date of Birth
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1919
Purchase Date
MM
MM
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02
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DD
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02
03
04
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YY
YYYY
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
Store Name
City of Retailer you Purchased From
State of Retailer you Purchased From
Retailer State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Which brand did you purchase?
Select Brand
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Black Hybrid
Hybrid
Legend
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Smartmotion
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Select Size
Select Size
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Full
Queen
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What type of base did you buy?
Which type of base did you buy?
Standard
Low-profile
Nuflex Foundation (adjustable)
ReNew PowerBase (adjustable)
Other
None
Price Paid
Rate your satisfaction with your mattress
1 of 5 Not at all satisfied
2 of 5 Not very satisfied
3 of 5 Somewhat satisfied
4 of 5 Very satisfied
5 of 5 Extremely satisfied
Rate the likelihood that you would recommend Beautyrest
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2 of 5 Not very likely
3 of 5 Somewhat likely
4 of 5 Very likely
5 of 5 Extremely likely
While shopping, where did you get your information?
(Check all that apply.)
Beautyrest Website
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Family or Friends
Doctor/ Chiropractor
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