* 1. Contact Information

* 2. Date

Date / Time

* 3. Using the scale below, please rate the following

  Poor Fair Average Good Excellent
The equipment and/or supplies arrived at the agreed upon time.
Adequate instructions were provided for the safe use of the equipment.
Our staff were courteous and helpful.
Overall customer satisfaction rating.
Overall satisfaction with our product.
Product quality.
Customer service.

* 4. How knowledgeable did our customer service representative seem to you?

* 5. How clear was the information that our customer service representative provided to you?

* 6. Were you satisfied with your last experience with our company, neither satisfied nor dissatisfied with it, or dissatisfied with it?

* 7. How well did our customer service representative answer your question or solve your problem?

* 8. Do you know who your local sales representative is?

* 9. Do you have your reps contact details?

* 10. Do you have any other comments, questions or concerns?