Country Life Bakery

First Name

*Last Name

*Email

*Gender

*Age

*Are you?

Other

List the ages of Coeliacs/Gluten Free Persons in your family (other than yourself)

*Where do you buy Gluten Free bread?

Coles

Woolworths

Bakery

Online specialty store

Other (Grocery Chain, Health Food Store etc):

*What is your main source of information about gluten free food (especially bread)?

Internet

Coeliac Society

Doctor/dietician

Friends/family

Other:

Please list the websites (if any) you visit for information in Coeliac/gluten free food

*Number of Gluten Free Loaves purchased each week?

CLB Gluten Free White:

CLB Gluten Free Multigrain:

CLB Gluten Free Low GI:

CLB Gluten Free Fruit:

Other Brands:

Please list other brands

What do you like about CLB?

How could CLB improve?

Ideas for new products or product improvements:

Yes, I would like to hear more about CLB products and future promotional offers

Personal details provided on this form will only be used by CLB to provide you with more information about our products and future promotional offers if you have ticked the box above. CLB will not provide these details to any third parties other than its promotional partners.

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