What is your first name?
Last Name?
What is your address:

City
 
State

 
ZIP

 
Telephone number with area code?
E-mail address?

What is your gender?
Male
Female
What is your age
 
Under 25
35 to 44
55 to 64
25 to 34
45 to 54
65 or older

Which of the following best describes your employment status?
 
Self-employed
Employed by someone else
Student
Currently unemployed or laid off
On strike or on leave, including maternity leave
Retired
Homemaker
Other

If you are self- employed or employed by someone else, what is the nature of your employment


Do your have children
Yes
No
 
If "Yes: Is child # 1
Male
Female
 
What is the birth date of child # 1
 
Is child # 2
Male
Female
 
What is the birth date of child # 2
 
Is child # 3
Male
Female
 
What is the birth date of child # 3
 
Is child # 4
Male
Female
 
What is the birth date of child # 4
 


What is your political affiliation
 
Democrat
Republican
Liberal
Independent

If you own a vehicle please fill out...
Vehicle #1 make
 
Model:
 
Year
 
Vehicle #2 make
 
Model:
 
Year:
 
Vehicle #3 make
 
Model:
 
Year:
 
Do you smoke
Yes
No
 
If "YES" What brand?
 
Who is your Internet service provider:

Are you able to look at the Internet and  speak on the
telephone at the same time?
Yes
No

Please list three of your hobbies or special interests:
1.
2.
3.

What was your approximate total family income in  2001?
 
Under $15,000
$15,000 to $24,999
$25,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 or more