philips.efmfeedback.com
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URL:
https://philips.efmfeedback.com/se/705E3ED85B21960101
Submission: On May 18 via manual from US — Scanned from DE
Submission: On May 18 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST /se/705E3ED85B21960101
<form class="form-horizontal" role="form" action="/se/705E3ED85B21960101" method="post" enctype="multipart/form-data" onsubmit="return ProcessPage();" novalidate="">
<script>
document.documentElement.className += " js";
</script>
<section class="header-wrapper">
<div class="p-logo-wrapper">
<div class="p-logo">
<a title="" target="_top" class="p-refresh"></a>
<span class="p-workmark-title p-default">Survey</span>
</div>
</div>
</section>
<div class="container-fluid page-content">
<div class="row">
<div class="col-md-10 col-md-offset-1">
<h1 id="S0" class="section-heading"> Register to Receive Your Free HeartStart M5071A/M5072A Pads </h1>
<p class="text-block" id="T1" tabindex="0"><span face="Verdana" font-size="16px" style="font-size: 16px; font-family: Verdana;">You should have recently received a letter and/or a postcard informing you a problem has been identified in the
Philips M5071A (adult) and M5072A (infant/child) AED pads that could pose a risk for patients or users. <span style="font-size: 12pt; font-family: Verdana;">M5071A Adult pads cartridges with a LOT number beginning with “Y” will be
replaced, free-of-charge. For customers withdevices more than 10 years old, we will not replace expired pads.</span><br
style="background-color: rgb(217, 235, 255); margin: 0px; padding: 0px; font-size: 16px; font-family: Verdana;"><br style="background-color: rgb(217, 235, 255); margin: 0px; padding: 0px; font-size: 16px; font-family: Verdana;">In order
to do this, we need you to verify some information about you and your AED(s). Key information fields are marked with an asterisk (<span color="#ff0000" style="color: rgb(255, 0, 0);">*</span>) please provide the information to the best of
your ability.</span></p><!--Q37_START-->
<fieldset id="Q37_WRAPPER" class="question shortanswer">
<legend id="Q37_LEGEND" class="sr-only">
<label for="Q37_1"></label>
</legend><span id="Q37_QUESTION_TEXT"><a id="Q37_HEADING" class="question-heading anchor"></a><label for="Q37_1" class="question-text"><span face="Verdana" style="font-family: Verdana;">Please provide the name of the distributor you order
supplies from. <span color="#ff0000" style="color: rgb(255, 0, 0);">*</span></span><br><span face="Verdana" style="font-family: Verdana;">If unknown, please type "unknown".</span></label></span>
<div class="response-set" aria-labelledby="Q37_QUESTION_TEXT" role="grid">
<div class="field-wrapper">
<input type="text" class="form-control" name="Q37_1" id="Q37_1" maxlength="255" role="textbox" aria-multiline="false">
</div>
</div>
<div id="Q37_1ReqAns" tabindex="0" class="alert alert-danger validation-message" role="alert" style="display:none;"> Please answer question 1 before continuing. </div>
</fieldset><!--Q37_END-->
<p class="text-block" id="T3" tabindex="0"><span style="color: rgb(0, 0, 0); font-family: Verdana;">If you received a letter with a Customer Code, please add the code below.<br><br><strong>Letter and postcard examples:</strong><br><img
src="/surveys/1885224664/5b219601/img001.jpg?AEA9C9A7" style="height: 140px; width: 450px;"> <img src="/surveys/1885224664/5b219601/img002.jpg?AEA9C9A7" style="height: 213px; width: 350px;"></span>
</p><!--Q40_START-->
<fieldset id="Q40_WRAPPER" class="question shortanswer">
<legend id="Q40_LEGEND" class="sr-only">
<label for="Q40_1"></label>
</legend><span id="Q40_QUESTION_TEXT"><a id="Q40_HEADING" class="question-heading anchor"></a><label for="Q40_1" class="question-text"><span face="Verdana" style="font-family: Verdana;">Customer Code</span></label></span>
<div class="response-set" aria-labelledby="Q40_QUESTION_TEXT" role="grid">
<div class="field-wrapper">
<input type="text" class="form-control" name="Q40_1" id="Q40_1" maxlength="255" role="textbox" aria-multiline="false">
</div>
</div>
</fieldset><!--Q40_END-->
<h1 id="S1" class="section-heading"> Tell us about yourself </h1><!--Q2_START-->
<fieldset id="Q2_WRAPPER" class="question shortanswer">
<legend id="Q2_LEGEND" class="sr-only">
<label for="Q2_1"></label>
</legend><span id="Q2_QUESTION_TEXT"><a id="Q2_HEADING" class="question-heading anchor"></a><label for="Q2_1" class="question-text"><span face="Verdana" style="font-family: Verdana;">Name <span color="#ff0000"
style="color: rgb(255, 0, 0);">*</span></span></label></span>
<div class="response-set" aria-labelledby="Q2_QUESTION_TEXT" role="grid">
<div class="field-wrapper">
<input type="text" class="form-control" name="Q2_1" id="Q2_1" maxlength="255" role="textbox" aria-multiline="false">
</div>
</div>
<div id="Q2_1ReqAns" tabindex="0" class="alert alert-danger validation-message" role="alert" style="display:none;"> Please answer question 3 before continuing. </div>
</fieldset><!--Q2_END-->
<!--Q3_START-->
<fieldset id="Q3_WRAPPER" class="question shortanswer">
<legend id="Q3_LEGEND" class="sr-only">
<label for="Q3_1"></label>
</legend><span id="Q3_QUESTION_TEXT"><a id="Q3_HEADING" class="question-heading anchor"></a><label for="Q3_1" class="question-text"><span face="Verdana" style="font-family: Verdana;">Organization/Company (if
applicable)</span></label></span>
<div class="response-set" aria-labelledby="Q3_QUESTION_TEXT" role="grid">
<div class="field-wrapper">
<input type="text" class="form-control" name="Q3_1" id="Q3_1" maxlength="255" role="textbox" aria-multiline="false">
</div>
</div>
</fieldset><!--Q3_END-->
<!--Q4_START-->
<fieldset id="Q4_WRAPPER" class="question shortanswer">
<legend id="Q4_LEGEND" class="sr-only">
<label for="Q4_1"></label>
</legend><span id="Q4_QUESTION_TEXT"><a id="Q4_HEADING" class="question-heading anchor"></a><label for="Q4_1" class="question-text"><span face="Verdana" style="font-family: Verdana;">Street address <span color="#ff0000"
style="color: rgb(255, 0, 0);">*</span></span></label></span>
<div class="response-set" aria-labelledby="Q4_QUESTION_TEXT" role="grid">
<div class="field-wrapper">
<input type="text" class="form-control" name="Q4_1" id="Q4_1" maxlength="255" role="textbox" aria-multiline="false">
</div>
</div>
<div id="Q4_1ReqAns" tabindex="0" class="alert alert-danger validation-message" role="alert" style="display:none;"> Please answer question 5 before continuing. </div>
</fieldset><!--Q4_END-->
<!--Q5_START-->
<fieldset id="Q5_WRAPPER" class="question shortanswer">
<legend id="Q5_LEGEND" class="sr-only">
<label for="Q5_1"></label>
</legend><span id="Q5_QUESTION_TEXT"><a id="Q5_HEADING" class="question-heading anchor"></a><label for="Q5_1" class="question-text"><span face="Verdana" style="font-family: Verdana;">City</span><span
style="background-color: rgb(255, 255, 255); font-size: 14px; font-family: Verdana;"> </span><span color="#ff0000" font-size="14px" bg-color="rgb(255, 255, 255)"
style="color: rgb(255, 0, 0); background-color: rgb(255, 255, 255); font-size: 14px; font-family: Verdana;">*</span></label></span>
<div class="response-set" aria-labelledby="Q5_QUESTION_TEXT" role="grid">
<div class="field-wrapper">
<input type="text" class="form-control" name="Q5_1" id="Q5_1" maxlength="255" role="textbox" aria-multiline="false">
</div>
</div>
<div id="Q5_1ReqAns" tabindex="0" class="alert alert-danger validation-message" role="alert" style="display:none;"> Please answer question 6 before continuing. </div>
</fieldset><!--Q5_END-->
<!--Q6_START-->
<fieldset id="Q6_WRAPPER" class="question shortanswer">
<legend id="Q6_LEGEND" class="sr-only">
<label for="Q6_1"></label>
</legend><span id="Q6_QUESTION_TEXT"><a id="Q6_HEADING" class="question-heading anchor"></a><label for="Q6_1" class="question-text"><span face="Verdana" style="font-family: Verdana;">State</span><span
style="background-color: rgb(255, 255, 255); font-size: 14px; font-family: Verdana;"> </span><span color="#ff0000" font-size="14px" bg-color="rgb(255, 255, 255)"
style="color: rgb(255, 0, 0); background-color: rgb(255, 255, 255); font-size: 14px; font-family: Verdana;">*</span></label>
<div id="Q6_INSTRUCTIONS" class="instruction-text"> If your address is in Washington DC, please leave the State box blank. </div>
</span>
<div class="response-set" aria-labelledby="Q6_QUESTION_TEXT" role="grid">
<div class="field-wrapper">
<select class="form-control" name="Q6_1" id="Q6_1" role="listbox">
<option id="Q6_1_0" value="" selected="selected" role="option" aria-selected="true"> </option>
<option id="Q6_1_1" value="Alabama - AL" role="option" aria-selected="false"> Alabama - AL </option>
<option id="Q6_1_2" value="Alaska - AK" role="option" aria-selected="false"> Alaska - AK </option>
<option id="Q6_1_3" value="Arizona -AZ" role="option" aria-selected="false"> Arizona -AZ </option>
<option id="Q6_1_4" value="Arkansas -AR" role="option" aria-selected="false"> Arkansas -AR </option>
<option id="Q6_1_5" value="California -CA" role="option" aria-selected="false"> California -CA </option>
<option id="Q6_1_6" value="Colorado -CO" role="option" aria-selected="false"> Colorado -CO </option>
<option id="Q6_1_7" value="Connecticut -CT" role="option" aria-selected="false"> Connecticut -CT </option>
<option id="Q6_1_8" value="Delaware -DE" role="option" aria-selected="false"> Delaware -DE </option>
<option id="Q6_1_9" value="Florida -FL" role="option" aria-selected="false"> Florida -FL </option>
<option id="Q6_1_10" value="Georgia -GA" role="option" aria-selected="false"> Georgia -GA </option>
<option id="Q6_1_11" value="Hawaii -HI" role="option" aria-selected="false"> Hawaii -HI </option>
<option id="Q6_1_12" value="Idaho -ID" role="option" aria-selected="false"> Idaho -ID </option>
<option id="Q6_1_13" value="Illinois -IL" role="option" aria-selected="false"> Illinois -IL </option>
<option id="Q6_1_14" value="Indiana -IN" role="option" aria-selected="false"> Indiana -IN </option>
<option id="Q6_1_15" value="Iowa -IA" role="option" aria-selected="false"> Iowa -IA </option>
<option id="Q6_1_16" value="Kansas -KS" role="option" aria-selected="false"> Kansas -KS </option>
<option id="Q6_1_17" value="Kentucky -KY" role="option" aria-selected="false"> Kentucky -KY </option>
<option id="Q6_1_18" value="Louisiana -LA" role="option" aria-selected="false"> Louisiana -LA </option>
<option id="Q6_1_19" value="Maine -ME" role="option" aria-selected="false"> Maine -ME </option>
<option id="Q6_1_20" value="Maryland -MD" role="option" aria-selected="false"> Maryland -MD </option>
<option id="Q6_1_21" value="Massachusetts -MA" role="option" aria-selected="false"> Massachusetts -MA </option>
<option id="Q6_1_22" value="Michigan -MI" role="option" aria-selected="false"> Michigan -MI </option>
<option id="Q6_1_23" value="Minnesota -MN" role="option" aria-selected="false"> Minnesota -MN </option>
<option id="Q6_1_24" value="Mississippi -MS" role="option" aria-selected="false"> Mississippi -MS </option>
<option id="Q6_1_25" value="Missouri -MO" role="option" aria-selected="false"> Missouri -MO </option>
<option id="Q6_1_26" value="Montana -MT" role="option" aria-selected="false"> Montana -MT </option>
<option id="Q6_1_27" value="Nebraska -NE" role="option" aria-selected="false"> Nebraska -NE </option>
<option id="Q6_1_28" value="Nevada -NV" role="option" aria-selected="false"> Nevada -NV </option>
<option id="Q6_1_29" value="New Hampshire -NH" role="option" aria-selected="false"> New Hampshire -NH </option>
<option id="Q6_1_30" value="New Jersey -NJ" role="option" aria-selected="false"> New Jersey -NJ </option>
<option id="Q6_1_31" value="New Mexico -NM" role="option" aria-selected="false"> New Mexico -NM </option>
<option id="Q6_1_32" value="New York -NY" role="option" aria-selected="false"> New York -NY </option>
<option id="Q6_1_33" value="North Carolina -NC" role="option" aria-selected="false"> North Carolina -NC </option>
<option id="Q6_1_34" value="North Dakota -ND" role="option" aria-selected="false"> North Dakota -ND </option>
<option id="Q6_1_35" value="Ohio -OH" role="option" aria-selected="false"> Ohio -OH </option>
<option id="Q6_1_36" value="Oklahoma -OK" role="option" aria-selected="false"> Oklahoma -OK </option>
<option id="Q6_1_37" value="Oregon -OR" role="option" aria-selected="false"> Oregon -OR </option>
<option id="Q6_1_38" value="Pennsylvania -PA" role="option" aria-selected="false"> Pennsylvania -PA </option>
<option id="Q6_1_39" value="Rhode Island -RI" role="option" aria-selected="false"> Rhode Island -RI </option>
<option id="Q6_1_40" value="South Carolina -SC" role="option" aria-selected="false"> South Carolina -SC </option>
<option id="Q6_1_41" value="South Dakota -SD" role="option" aria-selected="false"> South Dakota -SD </option>
<option id="Q6_1_42" value="Tennessee -TN" role="option" aria-selected="false"> Tennessee -TN </option>
<option id="Q6_1_43" value="Texas -TX" role="option" aria-selected="false"> Texas -TX </option>
<option id="Q6_1_44" value="Utah -UT" role="option" aria-selected="false"> Utah -UT </option>
<option id="Q6_1_45" value="Vermont -VT" role="option" aria-selected="false"> Vermont -VT </option>
<option id="Q6_1_46" value="Virginia -VA" role="option" aria-selected="false"> Virginia -VA </option>
<option id="Q6_1_47" value="Washington -WA" role="option" aria-selected="false"> Washington -WA </option>
<option id="Q6_1_48" value="West Virginia -WV" role="option" aria-selected="false"> West Virginia -WV </option>
<option id="Q6_1_49" value="Wisconsin -WI" role="option" aria-selected="false"> Wisconsin -WI </option>
<option id="Q6_1_50" value="Wyoming -WY" role="option" aria-selected="false"> Wyoming -WY </option>
<option id="Q6_1_51" value="Alberta -XA" role="option" aria-selected="false"> Alberta -XA </option>
<option id="Q6_1_52" value="British Columbia - XC" role="option" aria-selected="false"> British Columbia - XC </option>
<option id="Q6_1_53" value="Manitoba - XM" role="option" aria-selected="false"> Manitoba - XM </option>
<option id="Q6_1_54" value="New Brunswick - XB" role="option" aria-selected="false"> New Brunswick - XB </option>
<option id="Q6_1_55" value="Newfoundland - XW" role="option" aria-selected="false"> Newfoundland - XW </option>
<option id="Q6_1_56" value="Northwest Territories - XT" role="option" aria-selected="false"> Northwest Territories - XT </option>
<option id="Q6_1_57" value="Nova Scotia - XN" role="option" aria-selected="false"> Nova Scotia - XN </option>
<option id="Q6_1_58" value="Ontario - XO" role="option" aria-selected="false"> Ontario - XO </option>
<option id="Q6_1_59" value="Prince Edward Island - XP" role="option" aria-selected="false"> Prince Edward Island - XP </option>
<option id="Q6_1_60" value="Quebec - XQ" role="option" aria-selected="false"> Quebec - XQ </option>
<option id="Q6_1_61" value="Saskatchewan - XS" role="option" aria-selected="false"> Saskatchewan - XS </option>
<option id="Q6_1_62" value="Nunavut - XV" role="option" aria-selected="false"> Nunavut - XV </option>
<option id="Q6_1_63" value="Yukon Territory - XY" role="option" aria-selected="false"> Yukon Territory - XY </option>
<option id="Q6_1_64" value="Province Unknown - OT" role="option" aria-selected="false"> Province Unknown - OT </option>
</select>
</div>
</div>
</fieldset><!--Q6_END-->
<!--Q7_START-->
<fieldset id="Q7_WRAPPER" class="question shortanswer">
<legend id="Q7_LEGEND" class="sr-only">
<label for="Q7_1"></label>
</legend><span id="Q7_QUESTION_TEXT"><a id="Q7_HEADING" class="question-heading anchor"></a><label for="Q7_1" class="question-text"><span face="Verdana" font-size="14px" style="font-size: 14px; font-family: Verdana;"><span
face="Verdana">Zip</span></span><span style="background-color: rgb(255, 255, 255); font-size: 14px; font-family: Verdana;"> </span><span color="#ff0000" font-size="14px" bg-color="rgb(255, 255, 255)"
style="color: rgb(255, 0, 0); background-color: rgb(255, 255, 255); font-size: 14px; font-family: Verdana;">*</span></label></span>
<div class="response-set" aria-labelledby="Q7_QUESTION_TEXT" role="grid">
<div class="field-wrapper">
<input type="text" class="form-control" name="Q7_1" id="Q7_1" maxlength="255" role="textbox" aria-multiline="false">
</div>
</div>
<div id="Q7_1ReqAns" tabindex="0" class="alert alert-danger validation-message" role="alert" style="display:none;"> Please answer question 8 before continuing. </div>
</fieldset><!--Q7_END-->
<!--Q9_START-->
<fieldset id="Q9_WRAPPER" class="question shortanswer">
<legend id="Q9_LEGEND" class="sr-only">
<label for="Q9_1"></label>
</legend><span id="Q9_QUESTION_TEXT"><a id="Q9_HEADING" class="question-heading anchor"></a><label for="Q9_1" class="question-text"><span face="Verdana" style="font-family: Verdana;">Phone number</span><span
style="background-color: rgb(255, 255, 255); font-size: 14px; font-family: Verdana;"> </span><span color="#ff0000" font-size="14px" bg-color="rgb(255, 255, 255)"
style="color: rgb(255, 0, 0); background-color: rgb(255, 255, 255); font-size: 14px; font-family: Verdana;">*</span></label></span>
<div class="response-set" aria-labelledby="Q9_QUESTION_TEXT" role="grid">
<div class="field-wrapper">
<input type="text" class="form-control" name="Q9_1" id="Q9_1" maxlength="255" role="textbox" aria-multiline="false">
</div>
</div>
<div id="Q9_1ReqAns" tabindex="0" class="alert alert-danger validation-message" role="alert" style="display:none;"> Please answer question 9 before continuing. </div>
</fieldset><!--Q9_END-->
<!--Q8_START-->
<fieldset id="Q8_WRAPPER" class="question shortanswer">
<legend id="Q8_LEGEND" class="sr-only">
<label for="Q8_1"></label>
</legend><span id="Q8_QUESTION_TEXT"><a id="Q8_HEADING" class="question-heading anchor"></a><label for="Q8_1" class="question-text"><span color="#ff0000" font-size="14px" bg-color="rgb(255, 255, 255)"
style="color: rgb(255, 0, 0); font-size: 14px; font-family: Verdana;"><span style="color: rgb(0, 0, 0); font-size: 16px;">Email </span><span style="background-color: rgb(255, 255, 255);">*</span></span></label></span>
<div class="response-set" aria-labelledby="Q8_QUESTION_TEXT" role="grid">
<div class="field-wrapper">
<input type="email" class="form-control" name="Q8_1" id="Q8_1" maxlength="255" placeholder="Email" role="textbox" aria-multiline="false">
</div>
</div>
<div id="Q8_1ReqAns" tabindex="0" class="alert alert-danger validation-message" role="alert" style="display:none;"> Please answer question 10 before continuing. </div>
<div id="Q8_1EmailAddress" tabindex="0" class="alert alert-danger validation-message" role="alert" style="display:none;"> Your answer to question 10 must be a valid email address. </div>
</fieldset><!--Q8_END-->
<!--Q28_START-->
<fieldset id="Q28_WRAPPER" class="question chooseone list">
<legend id="Q28_LEGEND" class="sr-only">
</legend><span id="Q28_QUESTION_TEXT"><a id="Q28_HEADING" class="question-heading anchor"></a><span class="question-text"><span style="font-family: Verdana;">Is your shipping address the same as your contact address? </span><span
color="#ff0000" font-size="14px" bg-color="rgb(255, 255, 255)" style="color: rgb(255, 0, 0); font-size: 14px; font-family: Verdana;">*</span></span></span>
<div class="response-area" role="radiogroup" aria-labelledby="Q28_QUESTION_TEXT">
<ol class="response-set">
<li id="Q28C1" class="response select-area"><input type="radio" name="Q28" value="1" id="Q28_1" role="radio" aria-checked="false"><label for="Q28_1" class="choice-text">Yes</label></li>
<li id="Q28C2" class="response select-area"><input type="radio" name="Q28" value="2" id="Q28_2" role="radio" aria-checked="false"><label for="Q28_2" class="choice-text">No</label></li>
</ol>
</div>
<div id="Q28ReqAns" tabindex="0" class="alert alert-danger validation-message" role="alert" style="display:none;"> Please answer question 11 before continuing. </div>
</fieldset><!--Q28_END-->
<input type="hidden" id="CurrentPageId" name="CurrentPageId" value="1"><input type="hidden" id="SurveyId" name="SurveyId" value="705E3ED85B21960101"><input type="hidden" id="SessionKey" name="SessionKey"
value="ba4a2064-ff1d-4891-8b41-ea50d7d73414_-1348377787">
</div>
</div>
<div class="row">
<div class="col-xs-6 col-xs-offset-3 col-md-4 col-md-offset-4">
<div class="progress progress-incomplete-color" id="PB_1">
<div class="progress-bar progress-complete-color" role="progressbar" tabindex="0" aria-valuenow="14" aria-valuemin="0" aria-valuemax="100" aria-label="14%" style="width:14%;">
<span class="sr-only">14% Complete</span>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-md-10 col-md-offset-1">
<p id="BA"><input id="BN" type="submit" name="next" class="btn btn-primary button-text button-next" role="button" value="Next"></p>
</div>
</div>
<div class="row">
<div class="col-md-10 col-md-offset-1 text-center">
<small id="TL1" class="tagline perseus-link">
<a href="https://www.verint.com/experience-management/" target="_blank">Powered by Verint </a>
</small>
</div>
</div>
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</form>Text Content
Survey REGISTER TO RECEIVE YOUR FREE HEARTSTART M5071A/M5072A PADS You should have recently received a letter and/or a postcard informing you a problem has been identified in the Philips M5071A (adult) and M5072A (infant/child) AED pads that could pose a risk for patients or users. M5071A Adult pads cartridges with a LOT number beginning with “Y” will be replaced, free-of-charge. For customers withdevices more than 10 years old, we will not replace expired pads. In order to do this, we need you to verify some information about you and your AED(s). Key information fields are marked with an asterisk (*) please provide the information to the best of your ability. Please provide the name of the distributor you order supplies from. * If unknown, please type "unknown". Please answer question 1 before continuing. If you received a letter with a Customer Code, please add the code below. Letter and postcard examples: Customer Code TELL US ABOUT YOURSELF Name * Please answer question 3 before continuing. Organization/Company (if applicable) Street address * Please answer question 5 before continuing. City * Please answer question 6 before continuing. State * If your address is in Washington DC, please leave the State box blank. Alabama - AL Alaska - AK Arizona -AZ Arkansas -AR California -CA Colorado -CO Connecticut -CT Delaware -DE Florida -FL Georgia -GA Hawaii -HI Idaho -ID Illinois -IL Indiana -IN Iowa -IA Kansas -KS Kentucky -KY Louisiana -LA Maine -ME Maryland -MD Massachusetts -MA Michigan -MI Minnesota -MN Mississippi -MS Missouri -MO Montana -MT Nebraska -NE Nevada -NV New Hampshire -NH New Jersey -NJ New Mexico -NM New York -NY North Carolina -NC North Dakota -ND Ohio -OH Oklahoma -OK Oregon -OR Pennsylvania -PA Rhode Island -RI South Carolina -SC South Dakota -SD Tennessee -TN Texas -TX Utah -UT Vermont -VT Virginia -VA Washington -WA West Virginia -WV Wisconsin -WI Wyoming -WY Alberta -XA British Columbia - XC Manitoba - XM New Brunswick - XB Newfoundland - XW Northwest Territories - XT Nova Scotia - XN Ontario - XO Prince Edward Island - XP Quebec - XQ Saskatchewan - XS Nunavut - XV Yukon Territory - XY Province Unknown - OT Zip * Please answer question 8 before continuing. Phone number * Please answer question 9 before continuing. Email * Please answer question 10 before continuing. Your answer to question 10 must be a valid email address. Is your shipping address the same as your contact address? * 1. Yes 2. No Please answer question 11 before continuing. 14% Complete Powered by Verint