First Name * |
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Last Name * |
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Sex * |
Male
Female |
Marital Status * |
Single
Married
Divorced
Widowed
Unknown/Refused |
Address1 * |
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Address2 |
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City * |
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State * |
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ZIP * |
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County |
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Home Phone Number * |
Starting with the area code, digits only please - no hyphens or periods, and no "1" preceding the area code. The same applies to Work Phone, Fax and Cell Phone. |
Work Phone Number |
- ext:
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FAX Number |
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Cell Phone Number |
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Personal E-mail Address * |
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Race |
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Date of Birth (mm/dd/yyyy) * |
/
/
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Sexual Orientation |
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Party Affiliation |
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Primary Employment Status * |
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If employed: |
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Employer |
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Industry |
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Position |
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Number of Employees |
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Number of Employees Reporting Directly to You |
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Do you Travel for Business? |
Yes
No |
If yes, |
Domestic
International
Both |
Education * |
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Do you own a car? * |
Yes
No |
If Yes, |
Make |
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Model |
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Year |
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Do you own a second car? |
Yes
No |
If Yes, |
Make |
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Model |
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Year |
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Do you travel for pleasure? |
Yes
No |
If yes, |
Domestic
International
Both |
Are you a member of a Frequent Flyer Club? |
Yes
No |
Are you a member of a Hotel Rewards Club? |
Yes
No |
Gender:
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Birthdate:
mm/dd/yyyy |
Gender:
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Birthdate:
mm/dd/yyyy |
Gender:
|
Birthdate:
mm/dd/yyyy |
Gender:
|
Birthdate:
mm/dd/yyyy |
Gender:
|
Birthdate:
mm/dd/yyyy |
Gender:
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Birthdate:
mm/dd/yyyy |
Do you own or rent your home? |
Own
Rent |
What type of place do you live in? |
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Household Income |
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Which Credit Cards do you have?
Select all that apply. |
For lists with multiple responses, hold Control key down to select/unselect multiple responses |
Do you own a computer? |
Yes
No |
If yes, check all that apply: |
For lists with multiple responses, hold Control key down to select/unselect multiple responses |
Do you own a PDA? |
Yes
No |
If yes, check all that apply: |
For lists with multiple responses, hold Control key down to select/unselect multiple responses |
Are you online? * |
Yes
No |
If yes, Provider? |
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If online, primary type of connection? |
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Local phone service provider? |
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Long Distance phone provider? |
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Do you own a cell phone? |
Yes
No |
If yes, service provider? |
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Do you have a pet?
Select all that apply. |
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Do you smoke? |
Yes
Cigarettes
- Brand
Cigarette Type
Cigars
Pipe |
Do you drink?
Select all that apply. |
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Do you have a:
Select all that apply. |
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Do you or any members of your household regularly play video games? * |
No
Yes
If yes, check all that apply:
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Do you wear or use:
Select all that apply. |
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Do you have health insurance? |
Yes
No |
If yes, what type? |
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Do you have:
Select all that apply. |
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Where did you hear about us? |
Email
Friend
Newspaper
Magazine
Flyer
Craig's List
Web Site
Phone Call
Other
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