Welcome to the Orscheln Farm & Home Customer Satisfaction Survey. We value your candid feedback and appreciate you taking the time to complete our survey.

Please enter the following pieces of information from your receipt.

Store Number:

Date: -- 010203040506070809101112 / -- 01020304050607080910111213141516171819202122232425262728293031 / -- 20202021

Time: -- 000102030405060708091011121314151617181920212223 : -- 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859

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Amount Spent: .

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