LIPTON Tea - A Winner Every Day In May

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E-mail Address*
Title	Mr. Mrs. Ms.
First Name*
Last Name*
Address*
Address*
City*
State*
Zip*
Phone*

Date of birth*	Day	Month	Year
Date of birth*

How did you learn about this promotion? *

How health conscious are you? *

(One (1) being the least and ten (10) being the most)

Not at all					Extremely
1	2	3	4	5	6	7	8	9	10

How much do you agree or disagree with following statement? *

“I try to lead a healthy lifestyle but am not willing to sacrifice my
enjoyment of foods and beverages to do so.”

Agree Strongly	Disagree Strongly
Agree Somewhat	Disagree Somewhat
Neither Agree or Disagree

Which of the following TYPES of tea do you buy regularly? *

(check all that apply)

Tea Bags

Ready to Drink Iced Tea (in bottles or cans)

Powdered Iced Tea Mix

None of the above

Helping you with your everyday needs is important to us. Therefore, from time to time, we may wish to send you information, samples or special offers that we feel may be of interest to you regarding LIPTON® Tea products or other complementary brands from Unilever or other carefully-selected companies. If you would rather not opt-in to receive such information, please uncheck the box below. For more information, or to remove yourself from future contact, please visit our privacy policy.

	Yes, I would like to receive such information and offers.

	Yes, but I would like to receive such information and offers only from LIPTON® Tea.

(play win) (play game over)

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How did you learn about this promotion? *

How health conscious are you? *

How much do you agree or disagree with following statement? *

Which of the following TYPES of tea do you buy regularly? *

Of the next ten boxes of tea bags you purchase, how many will be from the LIPTON® brand? *

Of the next bottles/cans of iced tea you purchase, how many will be from the LIPTON® brand? *

Of the next ten canisters/jars of powdered iced tea you purchase, how many will be from the LIPTON® brand? *