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	Name & Address:

	Title:*

	Mr. Mrs. Ms. Miss

	*First Name / Initial / Last Name:*



	*Address:**



	Apt. / Suite #:



	*City:**



	*State/Province:**



	*Zip/Postal Code:**



	*E-mail Address:**



	Telephone Number*:

	( ) -

	Your Date of Birth (Optional):



	Marital Status (Optional):

	Married Single

	What is Your Profession? (Optional)

	Please Tell Us About Your Purchase:

	Date of Purchase:



	Product Reference (EX: USK BL 16909, USK HA 31535):



	Production Reference (EX: PO-B11079MFR or PO11-00082, indicated on the appliance):



	Name of Store Purchased:



	Proof of Purchase (PDF, GIF, JPEG, or TIFF) If you cannot provide and image of your proof of purchase you must either fax or mail in a proof of purchase or your registration is not complete.

	I’d like to receive Kalorik’s Super Sunday Sale emails each week offering a selection of items exclusively to Kalorik insiders at up to 70% off