| Thank you
for your interest in Profectiv Products. |
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| Desired Username: |
*
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| Desired Password: |
*
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| First
Name: |
*
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| Last Name: |
* |
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| Address
1: |
* |
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| Address
2: |
Optional
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| City: |
* |
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| Country: |
* Required |
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| State: |
* USA, Canada, Most EU, Other |
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| Postal
Code / Zip: |
* Required
for almost all |
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| Telephone: |
Optional |
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| Email: |
* Used to send your username and password |
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| Please
tell us about your hair so we can customize the sample combinations
that will work best for you. Do you suffer from any of these
common hair and scalp problems? |
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| Please
check all that apply: |
Breakage
Hair Dryness
Scalp Dryness
Chemical Damage
Split Ends
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Scalp Itching
Thinning Edges
Flaking
Heat Trauma
Dandruff
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| Current
Hair Style: |
Braids
Cornrows
Twists/Locs
Straight/Relaxed
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Wavy/Texturized
Natural
Other, please specify:
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| Do
you use a hair relaxer? |
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No Answer
At Home
Salon
Both Home/Salon
Do Not Relax |
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| Do
you use hair color? |
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No Answer
At Home
Salon
Both Home/Salon
Do Not Color |
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| Do
you wear? |
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No Answer
Bonded (Glue-In) Weave
Sew-In Weave
Do Not Use Extensions |
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| Optional:
Please share information that will help us better know Profectiv
consumers. |
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| How
did you learn about Profectiv? |
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| Please
check all that apply: |
Magazine Ad
Word of Mouth/Friend/Relative
Web Search
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Community Event/Expo
At Store Shopping
Other, please specify:
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| Age
Range: |
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