Thank you for taking the time to answer a few questions about your experience in our store! After you have answered all the questions, you will receive a coupon as a token of our appreciation. Let's get started!

First, there is an 11-digit numeric code on the receipt.   You can find this number at the top of your receipt (shown in the red box on the image below).

Of the three sets of numbers in the red box, please enter the SECOND SET OF NUMBERS that is printed on YOUR receipt.  In the example below, the number is "0004".   Please enter the number from YOUR receipt below.(Required.)

00010004001300140015001700220023002400300033003500360037003900420043004400460047004800510053005500570063006400650066006700690071007300740077007800790080008200830088008900910095009600970098009901000103010501070108011001110112011301140117012001230125012601340135013801440145014801600163016501660167016801690175017701820183018401860187018801890191019301970198019902020203020402050208020902120218021902210222022502260227022802310232023302340236023902400244024502520253025402550256025702580259026002620263026402650266026702690270027102720273027402750276027702780279028102820287030303040306030703080309031003110312031303150316031903200321032203230324032503260328032903300331033303340335033603370338033903410342034303440345034803490350035103540355035603570358035903600361036203630364036503660367036803690401050305040701070307050706070907100711071307210723072616031604160716101613161516161618162116221623162516261627162816301632163316341635163616371638163916421643164416471652826182628265826682678268826982708271

What is the city and state of the store?(Required.)

AL, FOLEYAL, BOAZAL, LEEDSAL, OPELIKAAZ, GLENDALEAZ, PHOENIXAZ, TUCSONCA, ALPINECA, ANDERSONCA, CABAZONCA, CAMARILLOCA, COMMERCECA, FOLSOMCA, GILROYCA, LAKE ELSINORECA, LIVERMORECA, MILPITASCA, NAPACA, ONTARIOCA, PISMO BEACHCA, SAN CLEMENTECA, SAN YSIDROCA, TRUCKEECA, VACAVILLECO, CASTLE ROCKCO, LOVELANDCO, THORNTONCT, CLINTONCT, MYSTICCT, WESTBROOKDE, REHOBOTH BEACHFL, DAYTONA BEACHFL, DESTINFL, ELLENTONFL, FT. MYERSFL, LUTZFL, MIAMIFL, NAPLESFL, ORLANDOFL, ST. AUGUSTINEFL, SUNRISEFL, THE VILLAGESFL, VERO BEACHFL, WEST PALM BEACHGA, BYRONGA, CALHOUNGA, COMMERCEGA, DALTONGA, DAWSONVILLEGA, LAWRENCEVILLEGA, LOCUST GROVEGA, POOLERGA, WOODSTOCKIA, WILLIAMSBURGID, BOISEID, POST FALLSIL, AURORAIL, ROSEMONTIL, TUSCOLAIN, EDINBURGHIN, FREMONTIN, MICHIGAN CITYKY, SIMPSONVILLELA, GONZALESLA, NEW ORLEANSMA, LEEMA, WRENTHAMMD, HANOVERMD, HAGERSTOWNMD, OCEAN CITYMD, QUEENSTOWNME, FREEPORTME, KITTERYMI, AUBURN HILLSMI, BIRCH RUNMI, BYRON CENTERMI, HOWELLMI, WEST BRANCHMN, ALBERTVILLEMN, EAGANMN, MEDFORDMN, NORTH BRANCHMO, BRANSONMO, CHESTERFIELDMO, MINERMO, OSAGE BEACHMS, BATESVILLEMS, GULFPORTMS, PEARLMS, SOUTHAVENMS, VICKSBURGNC, ASHEVILLENC, BLOWING ROCKNC, CHARLOTTENC, CONCORDNC, MEBANENC, NAGS HEADNC, ROCKINGHAMNC, SMITHFIELDNC, WINSTON-SALEMNE, GRETNANH, MERRIMACKNH, NORTH CONWAYNH, TILTONNJ, ATLANTIC CITYNJ, BLACKWOODNJ, ELIZABETHNJ, FLEMINGTONNJ, JACKSONNJ, LAFAYETTENJ, MATAWANNJ, TINTON FALLSNM, SANTA FENV, LAS VEGASNV, LAUGHLINNY, BELLPORTNY, CENTRAL VALLEYNY, DEER PARKNY, LAKE GEORGENY, NIAGARA FALLSNY, RIVERHEADNY, WATERLOOOH, AURORAOH, BURBANKOH, JEFFERSONVILLEOH, MONROEOH, SUNBURYOR, BENDOR, LINCOLN CITYOR, SEASIDEOR, TROUTDALEOR, WOODBURNPA, GETTYSBURGPA, GROVE CITYPA, HERSHEYPA, LANCASTERPA, PHILADELPHIAPA, POTTSTOWNPA, TANNERSVILLEPA, WASHINGTONPR, BARCELONETAPR, CANOVANASSC, BLUFFTONSC, GAFFNEYSC, MYRTLE BEACHSC, NORTH CHARLESTONTN, CROSSVILLETN, LEBANONTN, NASHVILLETN, PIGEON FORGETN, SEVIERVILLETX, ALLENTX, CANUTILLOTX, CONROETX, CYPRESSTX, HILLSBOROTX, KATYTX, LAREDOTX, MERCEDESTX, ROUND ROCKTX, SAN MARCOSTX, SULPHUR SPRINGSTX, TERRELLVA, LEESBURGVA, NORFOLKVA, WILLIAMSBURGVA, WOODBRIDGEVT, BRATTLEBOROVT, ESSEX JUNCTIONWA, AUBURNWA, BLAINEWA, BURLINGTONWA, CENTRALIAWA, NORTH BENDWA, TULALIPWI, BARABOOWI, JOHNSON CREEKWI, OSHKOSHWI, PLEASANT PRAIRIEWV, SUTTON