First Name
Last Name
Address
Apt, Suite, Unit, etc.
City
State Choose 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 Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ------ American Samoa (AS) Guam (GU) Marshall Islands (MH) N. Mariana Islands (MP) Palau(PW) Puerto Rico (PR) Virgin Islands (VI) Armed Forces - AE (AE) Armed Forces - AA (AA) Armed Forces - AP (AP) Zip Code
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Date of Birth Month ---------- January February March April May June July August September October November December Day ---------- 1 2 3 4 5 6 7 8 9 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
1. How did you hear about this sample?
Magazine ad In-home mailer Online (e-mail, ad, Google, Yahoo, etc) Sunday newspaper coupon insert Friend or family member Other, please specify
2. Which statement best describes how you feel about KOTEX® products?
The only brand of feminine hygiene products I use One of a number of brands of feminine care products I use A brand I use sometimes, but not preferably A brand I don't know, but might try in the future A brand I would never choose to use
Which brands of feminine protection products are you currently using? (Select all that apply)
3. Pads
Always pads Kotex® pads Stayfree pads Other pads, please specify Don't remember/I'm unsure Don't use pads
4. Pantiliners
Always liners Kotex® liners Carefree liners Other liners, please specify Don't remember/I'm unsure Don't use pantiliners
5. Tampons
Kotex® tampons Tampax cardboard tampons Tampax Pearl tampons o.b. tampons Playtex tampons Other tampons, please specify Don't remember/I'm unsure Don't use tampons
6. Do you wear pads specifically labeled for OVERNIGHT use on the package, such as Always Overnight Maxi or Kotex® Overnight Maxi, etc.?
Yes No Don't remember/I'm unsure Never heard of them
Yes, I'd like to receive Kotex® Extras, the newsletter filled with women's health articles and special offers on Kotex® products. No, I do not wish to receive the Kotex® Extras newsletter.
* While supplies last. Please allow 6-8 weeks for delivery. Available to U.S. residents only in continental U.S. You must be 13 or older to receive this sample. Limit one sample per household. Your privacy is important to us. Please click here to view the KOTEX® Privacy Policy.
