Your demographic information is kept in strict confidentiality

* Required field

General Information
First Name *
Last Name *
Sex * Male Female
Marital Status * Single Married Divorced Widowed Unknown/Refused
Address1 *
Address2
City *
State *
ZIP *
County
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:
FAX Number
Cell Phone Number
Personal E-mail Address *
Race
Date of Birth (mm/dd/yyyy) * / /
Sexual Orientation

Party Affiliation

Employment and Education
Primary Employment Status *
If employed:
Employer
Industry
Position
Number of Employees
Number of Employees Reporting Directly to You
Do you Travel for Business? Yes No
If yes, Domestic International Both
Education *
Travel Information
Do you own a car? * Yes No
If Yes,
Make
Model 
Year
Do you own a second car? Yes No
If Yes,
Make
Model 
Year
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
Children
Gender:
Birthdate:
mm/dd/yyyy
Gender:
Birthdate:
mm/dd/yyyy
Gender:
Birthdate:
mm/dd/yyyy
Gender:
Birthdate:
mm/dd/yyyy
Gender:
Birthdate:
mm/dd/yyyy
Gender:
Birthdate:
mm/dd/yyyy
Housing Information
Do you own or rent your home? Own  Rent
What type of place do you live in?
Financial Information
Household Income
Which Credit Cards do you have?

Select all that apply.

For lists with multiple responses, hold Control key down to select/unselect multiple responses
Technology
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

Communications
Are you online? * Yes   No
If yes, Provider?
If online, primary type of connection?
Local phone service provider?
Long Distance phone provider?
Do you own a cell phone? Yes   No
If yes, service provider?
Lifestyle
Do you have a pet?

Select all that apply.
Do you smoke? Yes
Cigarettes
- Brand

Cigarette Type

Cigars
Pipe
Do you drink?

Select all that apply.
Do you have a:

Select all that apply.
Do you or any members of your household regularly play video games? *
No   Yes
If yes, check all that apply:
Health and Medical
Do you wear or use:

Select all that apply.
Do you have health insurance? Yes   No
If yes, what type?
Do you have:

Select all that apply.
Referral Source
Where did you hear about us? Email
Friend
Newspaper
Magazine
Flyer
Craig's List
Web Site
Phone Call
Other