Date: Email Address Home:
Sex: Email Address Work:
Name: Education:
Address 1: Race:
Address 2: Specify Race:
City: Household Income:
State: Date Of Birth:
Zip:
Marital Status:
Home Phone:
-
Spouse Name:
    Spouse DOB:
Cell Phone: - Spouse Employment:
Employment: Spouse Occupation:
Occupation: Spouse Industry:
Industry: SpouseWork Phone:
-
Home Phone:
-
SpouseWork Fax:
-
Cell Phone:
-
Spouse Education:

Please list the name, sex and DOB of all the children living in your household (Ex. Mary F 10/1/93, Jason M 7/25/87):
What county do you live in?
Are you registered to vote? YES NO
Please list all types of alcohol consumed in your household:
Specify alcohol:
Primary Bank:

Computer? YES NO
Do you have Internet Service? YES NO
Name of Provider:

Pets? Cat Dog Other

Do you smoke? YES NO
Cigarettes? YES NO
Brand:
Chewing Tobacco? YES NO
Brand:
Smokeless Tobacco? YES NO
Brand:

Please list the year, make and model of all cars owned by your household.
Make: Model: Year:
Make: Model: Year:
Make:
Model: Year:

Please list all the radio stations listened to in your household:
What TV stations are watched most frequently for local news in your household?
Specify TV stations:
What long distance phone carrier do you use?
What local phone service do you use?