New Customer Survey Thank you for taking part in Darque Tan's Customer Survey. We will happily award new customers with a Free Level 2 session upon submission of this survey form. All information will be held confidential and not be used for any other purposes than Customer Service. Personal Information Customer Name(required) Customer Number (required) Customer City Customer State TX Alabama Alaska Alberta 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 Brunswick New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Ontario Oregon Pennsylvania Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Customer Phone number (required) (If any follow-up is needed) Email Address (required) (If any follow-up is needed) Survey Questions 1. What was the name of Employee that signed you up? (required) 2. Did the employee explain to always alternate their lotions? (required) Yes No 3. Did the employee explain to always take it up a level? (required) Yes No 4. Did the employee customize a tan plan on the back of your folded card? (required) Yes No 5. How would you rate the employee and their service? (required) 3-Average 1-Poor 2-Acceptable 3-Good 4-Great Sign-up Date Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year 2008 2009 2010 Additional Comments