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Fields marked with an asterik (*) are required
   
*First Name
*Last Name
*Address
Apt, Suite, Unit, etc
*City
*State   *Zip
*Gender Female Male
*Date of Birth      
*Email
   
Do you currently use feminine pad products with wings?
Yes
No
   
Which brands of feminine protection products are you currently using? (Select all that apply)
Thick Pads
 
Ultra Thin Pads
 
Pantiliners
 
Tampons
 
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 hygiene products I use
A brand I use in certain circumstances but not preferably
A brand I don't use now, but might try in the future
A brand I would never choose to use
   
How did you hear about our free sample offer?
A BrandPower TV ad (live spokesperson)
An animated TV ad
A magazine ad
A friend or family member
An in home mailing
An email from Kotex
An online banner ad
A search engine (Google, Yahoo, etc.)
Newspaper coupon insert
Other
   
 
 
 
*While supplies last. Please allow 6-8 weeks for delivery. Available to U.S. Residents only.
   
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