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Please complete your details to receive more information and special offers.
First Name:
Last Name:
Sex:
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Male
Female
Address:
City:
State:
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ACT
NSW
NT
QLD
SA
TAS
VIC
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Which age group do you fall into?:
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Under 25
25-34
35-44
45-54
55-59
60+
Email:
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Do you own a Philips SENSEO® coffee pod machine?
Yes, I received it as a gift
Yes, someone else in my household purchased one
Yes, I purchased one myself
No
Do we have your permission to contact you in the future with information and promotions from our company?
Yes
No
What type of coffee do you drink most often in your household?
Instant
Drip Filter
Percolator
Plunger
Cappuccino/Espresso
SENSEO®
Other
How many cups of coffee (of any kind) are consumed in your houseold during an avarage week?
None
1-5
6-10
11-15
16-20
21-25
26-30
more than 30
What brand of coffe do you buy most often?
Select one
Moccona instant
Moccona ground coffee
Moccona SENSEO®
Nescafe Blend 43
Nescafe Gold
Maxwel House
International Roast
Vittoria
Harris
Riva
Lavazza
Illy
Other