Survey Form

Mod Chip World Feedback

Information about your Model for Ordering

The purpose of this model things is too help you to understand which picture you going to soldering and I will post the picture on the net so just submit the follwing information and I will e-mail you.

This form is divided into the following sections:

Fill out the information in each section as requested. Then at the end of the form supply your name and contact information, and submit the form. You will receive a confirmation message from us shortly.

SECTION A -- Playstation Games

These are the instructions for filling out this section. These are the instructions for filling out this section.These are the instructions for filling out this section.

  1. What is your favorite game from playstation?



  2. How many hours of playstation do you play per week:

    None 1-5 hours 5-10 hours 10-20 hours More than 20 hours

  3. We would like to send you some Free Gift*. What is your mailing address? 
    Name     
Street   
City     
State    
Zip Code
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SECTION B -- Other Information

These are the instructions for filling out this section. These are the instructions for filling out this section. These are the instructions for filling out this section.

  1. How would you rate this free gift thing?

    Bad Poor Fair Good Excellent

  2. What is your favorite RPG Games?



  3. Select the type of games you are most interested in:

    RPG
    Fighting
    Stooter
    Sports
    Adventure

  4. Here's another way of collecting address info without using fixed-width text:

    Username
    Password
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SECTION C -- Title of this section

These are the instructions for filling out this section. These are the instructions for filling out this section. These are the instructions for filling out this section.

  1. Which of Playstation Model do you currently own? 
    SCPH1000     SCPH3000	SKU-07     SKU-10
SKU-02     SKU-05     SKU-08     SKU-11
SKU-03     SKU-06     SKU-09     SKU-12
  2. Please enter any additional comments regarding our products or services:



  3. Select a month from the following list, which shows 6 elements at a time:

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FORM SUBMISSION

Thank you for taking the time to answer the questions in our free gift.

This explains how we plan to use the information you provide to us. We will also explain what benefits you receive from helping us in this way.

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H.S Computer
Copyright © 2000 [Mod Chip World]. All rights reserved.
Revised: July 01, 2000.