Alpecin HYBRID Caffeine Liquid & Caffeine Shampoo Project Trial- RECRUITMENT SURVEY (male trialists only)

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* 1. Personal Information (male trialist please)

Full Name *

Physical Daytime Address (This address has to be your exact day time address and cannot be changed) *

Address line 2

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Email Address *

Cell Phone Number *

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* 2. Your Age: (male trialist please)

Under 18 years old

18-24 years old

25-30 years old

31-35 years old

36-44 years old

45-54 years old

55 and above

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* 3. Your Race: (male trialist please)

Asian

Black

Coloured

Indian

White

Mixed

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* 4. Are you available from 22nd May to the 17th June to take part in this Alpecin Hybrid Caffeine Liquid & Alpecin Hybrid Caffeine Shampoo project? (male trialist please)

Yes

No

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* 5. Do you want to review Alpecin Hybrid Caffeine Liquid and shampoo and share your experience? (male trialist please)

Yes

No

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* 6. Are you willing to take part in this project as a trade exchange? (male trialist please)

Yes

No

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* 7. What is your level of interest in your hair care? (male trialist please)

High

Medium

Low

Not interested at all

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* 8. Do you suffer from dry, itchy scalp? (male trialist please)

Yes

No