First Name *

Middle Initial

Last Name *

Home Address *

Home Address 2

City *

State * State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code *

Home Phone *

Work Phone

Fax

Date of Birth

Email Address *

Gender * Male
Female

Marital Status * Married
Not Married

Current Occupation * Choose Occupation Clerical or Service Worker Professional/Managerial Laborer or Machine Operator Technical/Sales/Administrative Education Medical Other Not employed at this time

Employment Status * Not Employed
Full Time
Part Time

Current Industry *

Job Title *

When can we reach you by phone? * (CHECK ALL THAT APPLY)
Weekdays
Week Day Mornings
Week Day Afternoons
Week Day Evenings
Or Weekends

Education Level * Choose education level Some high school or less High school graduate Some college 2-year college/technical school graduate 4-year college graduate Some postgraduate work Postgraduate degree

Which of the following describes your current residence? * Choose Current Residence Own-Single Family Own-Condo/Town House Rent-Single Family Rent-Condo/Townhouse Rent-Apartment Live rent free

Which of the following categories best describes your total, annual household income, before taxes? * Choose Income Here Less than $20,000 $20,000 but less than $34,999 $35,000 but less than $50,000 $50,000 but less than $75,000 $75,000 but less than $100,000 $100,000 but less than $125,000 $125,000 but less than $150,000 $150,000 or more

Which of the following categories most closely represents your ethnic background? Choose a background African American Asian Caucasian Hispanic Middle Eastern Native American Other

Do you own and use any of the following? (CHECK ALL THAT APPLY)
Pager
Cell Phone
Laptop
Palm Pilot

Do you currently use a computer? Yes
No

Do you access that computer from... Home
Work

Do you have access to the Internet? Yes
No

Do you have access to e-mail? Yes
No

On average, how many hours a week do you typically spend online? Choose Hours Here Less than 1 hour 1 to 3 hours 4 to 8 hours 8 or more hours

Have you ever made any purchases online? Yes
No

What type of credit cards you currently use? Mastercard
Visa
American Express
Discover
Debit Card

Including yourself, how many people are in your household? * Choose Number Here One Two Three Four Five More than 5

Because we sometimes conduct market research on behalf of companies for children's products, please provide the gender and date of birth for up to six children in your household:

We will add your number to our database and call you from time to time to see if you are interested and qualified to participate in a market research study where you are paid for your time.