| FIREARM INFORMATION |
| *Model Number: |
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| *Serial Number: |
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| *Purchase Date: |
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| PURCHASER'S NAME AND ADDRESS |
| *First Name: |
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| *Last Name: |
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| *Address: |
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| *City: |
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| *State |
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| *Zip: |
(Example: 12345) |
| *Phone: |
(Example: 812-555-1212) |
| *Email: |
(Example: name@domain.com) |
| I would like to receive future product information and company news from Uberti and other Benelli USA brands. |
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WARRANTY ASSIGNED TO
Same as Purchaser information above |
| *First Name: |
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| *Last Name: |
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| *Address: |
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| *City: |
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| *State |
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| *Zip: |
(Example: 12345) |
| *Phone: |
(Example: 812-555-1212) |
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| DEALER'S NAME AND ADDRESS |
| *Name: |
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| *Address: |
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| *City: |
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| *State |
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| *Zip: |
(Example: 12345) |
| *Phone: |
(Example: 812-555-1212) |
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| Your answers to the following questions will help us to better serve you. |
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Type of store where this firearm was purchased:
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Primary use of this firearm:
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What made you choose this firearm?
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Do you own other Uberti firearms?
Yes No
If yes, what models?
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Is there another Uberti firearm model you would like to own?
Yes No
If yes, what model?
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Would you recommend a Uberti product to others?
Yes No
If no, why not?
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Which firearms/outdoor magazines do you read?
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Which group best describes your annual household income:
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What is your age group?
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You are:
Male Female
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Your employment:
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Your education:
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