| Thank you for your interest in
Profectiv Products. |
|
| If you have recently received a postcard from us with a customer number printed on it, please enter that number here and continue to complete this form. This will help us correct your address so you can receive your samples. Thank you. |
|
|
| First Name: |
* |
|
| Last Name: |
* |
|
| Address 1: |
* |
|
| Address 2: |
Optional |
|
| City: |
* |
|
| Country: |
* Required |
|
| State: |
* USA, Canada, Most EU, Other |
|
| Postal Code / Zip: |
* Required for almost all |
|
| Telephone: |
Optional |
|
| Email: |
* Used to confirm your request |
|
|
|
|
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? |
|
|
|
| Please check all that apply: |
Breakage
Hair Dryness
Scalp Dryness
Chemical Damage
Split Ends
|
Scalp Itching
Thinning Edges
Flaking
Heat Trauma
Dandruff
|
|
|
|
|
|
|
|
|
|
|
|
| Current Hair Style: |
Braids
Cornrows
Twists/Locs
Straight/Relaxed
|
Wavy/Texturized
Natural
Other, please specify:
|
|
|
|
| Do you use a hair
relaxer? |
|
|
No Answer
At Home
Salon
Both Home/Salon
Do Not Relax
|
|
|
|
| Do you use hair
color? |
|
|
No Answer
At Home
Salon
Both Home/Salon
Do Not Color
|
|
|
|
| Do you wear? |
|
|
No Answer
Bonded (Glue-In) Weave
Sew-In Weave
Do Not Use Extensions
|
|
|
|
| Optional: Please share information
that will help us better know Profectiv consumers. |
|
|
|
| How did you learn about
Profectiv? |
|
| Please check all that apply: |
Magazine Ad
Word of Mouth/Friend/Relative
Web Search
|
Community Event/Expo
At Store Shopping
Other, please specify:
|
|
|
|
| Age Range: |
|
|
|
|
