CUSTOMER INFORMATION
First Name:	Last Name:	Title:
Company or Organization:	Department:	Address:
Address 2:	City:	State/Province:
Zip/Country Code:	Country:	E-mail:
Phone:	Fax:
Model:	Serial Number:	Date Installed:
Did a Grass Technologies Field Service Technician install your product?     YES     NO
Did the product run properly upon installation?     YES     NO
Are you completely satisfied with this product?     YES     NO
If no, please describe how you would improve it:
Please describe your involvement with your Grass Technologies product: I use/will use Grass Technologies products I recommend the purchase of Grass Technologies products Both Neither
Which of the following best describes your job function?   Research Clinical Researcher Physician Lab Technician Technologist Student Biomedial Engineer Purchasing Agent Purchasing Agent Other: Other:
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USAGE INFORMATION
What is the primary interest of your company? Electroencephalography Polysomnography Long-term Epilepsy Monitoring Biology Neurosciences Pharmacology Physiology Other:
For what application(s) will you use your Grass Technologies instrument?
Is this a new requirement or are you replacing an existing system?                                New requirement                              Replacing existing system
If this is replacing an existing system, what system is it replacing?
OTHER INFORMATION
Where did you hear about us ?  (check all that apply) Trade Show Mailing Web Search Magazine Ad Referral Web Ad Other: