Date: Email Address Home:
Sex: Email Address Work:
Name: Education:
Address 1: Race:
Address 2: Specify Race:
City: Household Income:
State: Date Of Birth:
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
Chewing Tobacco? YES NO
Smokeless Tobacco? YES NO

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