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Your Email Address (full address-i.e. john@iopinion.com)

Your Email Address (VERIFY)

Home Phone

Area Code Number

Business Phone

Area CodeNumber

Home Address

Street Address:

City:, State:Zip:

Male Female

Birthdate: Day: Year:

Marital Status: Ethnic Background:

Do you speak Spanish? NoYes

Household Income:  Last Level of Education

I have a computer at home:Yes No  

I access the Internet at home: Yes No

Who is your long distance carrier? Do you have a car or cell phone? Yes No

Which of the following credit cards do you carry?

 American Express  Discover
 Carte Blanche  Master Card
 Diners Club  Visa

Which of the following, if any, do you drink?

 Beer  
 Wine  
 Liquor  

Which of the following, if any, do you smoke?

 Cigarettes  
 Cigars  
 Pipes  

If applicable, brand of cigarettes smoked most often:

Please describe the cars in your household:

Year:

Year:

Year:

What type of home do you live in? Own Rent

Do you have a dog?Yes No Do you have a cat?Yes No

Please list the birthdates and sexes of children under 18 living in your household:

Birthdate:Day: Year: Gender:

Birthdate:Day: Year: Gender:

Birthdate:Day: Year: Gender:

Job Profile:

Full Time Part Time

Industry

Role in Company:

Department within Company:

Do you travel for business? YesNo

Are you responsible for selecting/purchasing computers, hardware, etc. at work? YesNo

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