Prototype Customer Demographic Collection Form

Goal: Collect customer demographic information in order to send out information to our customers about sales and in-store events.

Requirements:
1. customer's name, mailing address, e-mail address and telephone number
2. Upon submission of the information, the customer should be directed to another HTML page that acknowledges receipt of their information.

3. Change Request: Validate required fields.

Please join our customer mailing list so that we may keep you informed about sale opportunities and in-store events.

Full Name *


Address *

City, State, Zip Code *

Telephone Number *

E-Mail Address *

(please ensure all fields marked with * are filled in properly)

 

 

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