* First Name:		* Last Name:
* Address 1:		Address 2:
* City:
* State:	- Select State- Alabama Alaska American Samoa Arizona Armed Forces Africa Armed Forces Americas Armed Forces Canada Armed Forces Europe Armed Forces Middle East Armed Forces Pacific Arkansas California Colorado Connecticut Delaware District Of Columbia Federated States Of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
* ZIP Code:		* Email Address:
* Gender:	Female Male

1. Birthdate: - 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
   
   
2. Do you have children in your household? (Select each age range that applies)
   0-2 years old
   3-5 years old
   6-8 years old
   9-11 years old
   12-13 years old
   Older than 13
   No children
   
   
3. Which types of skin care products do you, or would you, use? (Select all that apply)
   Facial Cleanser
   Facial Moisturizer
   Body Moisturizer
   Body Wash
   Bar Soap
   Sunscreen / Sun protection
   Deodorants
   Lip Care
   Hand Cream
   
   
4. Which categories of Eucerin products are you interested in? (Select all that apply)
   Specific care products for rosacea, redness-prone or easily irritated skin
   Daily moisturizers with sun protection (SPF)
   Baby care (ointments, washes, etc.)
   Itchy skin relief
   Dry skin relief
   Summer moisturizers
   Sensitive skin moisturizers
   Fragranced
   Therapeutic / Healing
   Anti-wrinkle
   
   
5. Do you, or someone you care for, have any of the following skincare concerns? (Select all that apply)
   Very Dry Skin
   Itchy Skin
   Sensitive Skin
   Facial Redness
   Hyperpigmentation
   Bumpy Skin (keratosis pilaris)
   Very Dry Lips
   Dry Skin due to diabetes
   Psoriasis
   Rosacea
   Acne
   Atopic Dermatitis (eczema)
   Radiation Burn (from cancer treatment)
   Wrinkles
   Irritation due to cosmetic procedures
   Sun Sensitivity due to medication
   Brittle, dry nails and cuticles
   Age spots / dark spots
   
   
6. Are you involved in any of the following activities or professions? (Select all that apply)
   Running
   Swimming
   Cooking
   Winter Sports
   Gardening
   Sunbathing / beach outings
   Tattoo Art
   Cycling
   Hiking
   Golfing
   Tennis
   Cosmetologist / Aesthetician
   Doctor / Medical Professional
   Teacher
   Chef
   Other
   
   
7. Where do you prefer to shop for skincare products? (Select all that apply)
   Wal-Mart
   CVS
   Target
   Rite-Aid / Brooks
   Walgreens
   Costco
   Other