Warranty Registration

About you:

First Name
Last Name
Address 1
Address 2
City
State or Province	---Select a State or Province--- Alabama Alaska Arizona Arkansas California Colorado Connecticut Washington, DC Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland And Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
ZIP or Postal Code:
Phone:	( ) -
Email:

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About your Regency

Brand	-- Choose Brand -- Regency Hampton Excalibur
Model	Model #
Serial #
For help in finding the Model # and Serial # click here.
Date Purchased	/ / mm/dd/yyyy

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About your Dealer

Dealer Name		Dealer Code:
City
State or Province	---Select a State or Province--- Alabama Alaska Arizona Arkansas California Colorado Connecticut Washington, DC Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland And Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
Were you satisfied with your dealer?	Yes No
If no, why not?

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Other Information

What motivated your purchase? (select one)

---Select Application--- Replace older unit Emergency backup Remodeling or addition New home Hard to heat area Energy Savings

Where did you install your Regency?

---Please Select A Room--- Living Room Family Room Basement Kitchen Bedroom Other

How else do you heat your home?

---Please Select A Heat Source--- Fireplace Gas forced air Oil forced air Electric forced air Radiator Woodstove Electric Baseboard Gas fireplace No other heat source Other Heat Source

Where did you hear about Regency?

---Please Select a Referral Source--- TV Magazine Web Radio Friend Home Show Direct mail Flyer Newspaper Contest In Store Other

What was important to you when choosing your hearth product? (Choose all that apply)

	Not Applicable	Somewhat Important	Very Important
Price
Brand Name
Quality
Heat Output
Ability to customize the look
Efficiency
Warranty
Local Service

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Do you wish to receive information about special promotions or other Regency products?

Yes No

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Please type the two words (shown in black):