Product Registration

First Name*

Last Name*

Address 1

Address 2

City

State

Zip

Email Address*

Gender*

Male Female

Age*

Date of Purchase* (mm/dd/yyyy)

Name of store/website where purchased

Price paid (excluding sales tax)

Model

YellowTop
RedTop
BlueTop

Type of vehicle in which battery will be used:

Automobile/Truck
Boat/RV
Equipment (agricultural, construction, etc)
Other

Vehicle Make

Model

Year

How did you first become aware of OPTIMA?

Friend/relative's recommendation
Salesperson's recommendation
Television advertisement
Magazine advertisement/article
Online research
Store display
Store circular/flyer
Events (racing, fishing, etc)
Other (please specify)

What were the most important features that influenced your selection of this product?

Are there any other vehicles in your household with an OPTIMA battery?

Yes No

Vehicle Make

Model

Year

This purchase was:

First time buying an OPTIMA
A replacement for another OPTIMA
An additional OPTIMA product