Date of birth*	Day	Month	Year
	12345678910111213141516171819202122232425262728293031	January February March April May June July August September October November December	1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008

Subscribe to Lipton's Tea & Health Club e-mail newsletter. *

Which of the following brands has anyone in your household purchased in the last 12 months? *
AXE®	Degree®
'all'®	Snuggle®
Vaseline®	Caress®
Lever2000®	Dove® Bar
Suave®	Q-Tips®
SlimFast®	Lawry's®
Skippy®	LIPTON® Tea
Bertolli®	Hellmann's®/Best Foods®
Wish-Bone®	Shedd's Spread Country Crock®
Promise®	Ragu®
Knorr®	I Can't Believe It's Not Butter!®
Ben&Jerrys®

How often do you make food choices to maintain/improve your health? *
Frequently	Often	Rarely	Never
How often do you exercise? *
Frequently	Often	Rarely	Never
How often do you take vitamins or supplements for overall health? *
Frequently	Often	Rarely	Never
How often do you drink a lot of water? *
Frequently	Often	Rarely	Never

How health conscious are you?* one(1) being the least and ten(10) being the most
1	2	3	4	5	6	7	8	9	10

How much do you agree or disagree with the 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?*
Tea Bags Ready to Drink Iced Tea (in bottles or cans) Powdered Iced Tea Mix None of the above
Of the next ten boxes of tea bags you purchase, how many will be from the LIPTON Brand?
Of the next ten bottles of iced tea you purchase, how many will be from the LIPTON Brand?
Of the next ten packages of powdered iced tea mix you purchase, how many will be from the LIPTON Brand?

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.

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