Please complete all fields accurately and completely.
All fields with asterisks
are required and invalid information
may disqualify your submission. |
| First Name: * |
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| Last Name: * |
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| E-mail: * |
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| Street Address: |
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| City: |
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| State: |
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| Zip/Postal Code: |
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| Telephone: |
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| Mobile Phone: |
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| Mobile Carrier: |
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| Other Carrier: |
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| Demographic Information: |
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| Gender: |
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| Date of Birth: |
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| Income: |
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| Are you a parent of
a child under 18 currently living in
your household? |
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| Number of Children: |
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| What is the age of your child? |
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| What grade is your child in? |
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| Do you have a child planning to attend college? |
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| Are you expecting a new child? |
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| If yes, when? |
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What type of parenting information interests you the most?
Select all that apply. |
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| Marital Status: |
| Marital Status: |
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| Are you engaged? |
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| Do you plan on getting married in the next year? |
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| Household Information: |
| Do you own or rent your
residence? |
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| Dwelling Type: |
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| Household Income: |
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| Questions for Renters: |
| Are you interested in purchasing a home? |
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| Are you interested in building a new home? |
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| Are you interested in purchasing an existing home? |
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| If so, in what timeframe? |
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| Would you be interested in receiving mortgage offers? |
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| Will you be using a moving company? |
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| Are you using a real estate agent to assist you with your search? |
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| Educational Information: |
Highest Level of Education:
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| Are you currently attending college? |
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| What type of college or university are you currently attending? |
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| What year are you currently in? |
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| If you are not currently enrolled, do you plan on attending
a college or a university? |
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| Employment/Career Information: |
| Employment Status: |
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| Industry Employed In: |
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| Job Title: |
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Are you interested in
a career change?
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| Are you in the Armed
Forces? |
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| Are you considering
leaving the Armed Forces? |
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Are you a US Veteran?
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| Behavior/Lifestyle Demographics: |
| What political party
are you? |
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| Are you an active political donor? |
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| What is your ethnicity? |
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What nationality are you?
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Would you like to receive
offers relating to your
ethnic background?
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| What is your preferred language? |
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| What is your religion? |
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What type of vehicle
do you drive?
Please indicate Make, Model and Year |
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Are you planning to purchase
a new vehicle soon?
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| Is your home currently
equipped with an alarm system? |
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| Do you own a boat? |
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| Do you own a motorcycle? |
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| Do you own a pet? |
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| Please select which pets you own (Choose all that apply): |
Dog
Cat
Fish
Bird
Gerbil/Hamster
Ferret
Rabbit
Reptile
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| What brand of pet food do you purchase? |
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| Investing/Insurance Demographics: |
| Are you interested in
investing in financial products? |
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| Are you interested in
investing in real estate? |
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| Are you interested in
purchasing insurance? |
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| If yes, what kind of
insurance? |
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| Buying/Shopping Demographics: |
| Are you a wine enthusiast? |
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| What type of wine do
you enjoy? |
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| Do you consider yourself a cheese enthusiast? |
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| Do you enjoy coffee? |
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| How many cups of coffee
do you drink per day? |
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| What is your preference for purchasing coffee? |
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| Do you smoke? |
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| If yes, do you smoke cigarettes or cigars? |
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| Are you planning to quit smoking? |
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| Do you use smokeless tobacco products? |
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| Are you planning to quit using smokeless tobacco products? |
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| Do you use a major credit card to make online purchases? |
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| Do you shop online? |
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| Do you shop from catalogs? |
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| Do you like to shop with coupons? |
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| Do you like to shop in high end retail stores? |
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| Do you like to shop in discount warehouses? |
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| Do you enjoy fast
food? |
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| How many times a
week do you eat fast
food? |
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| Who does the grocery shopping in your household? |
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| How often do you go grocery shopping? |
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| Do you use coupons when you go grocery shopping? |
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| Do you purchase food in bulk? |
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| Do you purchase organic food? |
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| When was the last time you purchased cosmetics
or fragrances? |
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| Are you - or your parents - looking at senior/retirement communities as an alternate to staying in your own home? |
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| What brand of gasoline do you prefer? |
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| What type of fuel do you use in your vehicle? |
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| How often do you fill your gas tank? |
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| Would you like to receive offers for gasoline promotions? |
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| Are you interested in buying furniture for your residence? |
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| Are you interested in remodeling your home? |
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| Do you own a platinum or premium credit card? |
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| Are you a premier airlines rewards member? |
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| Are you a premier hotel rewards member? |
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| Do you belong to any premium dining clubs? |
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| Do you fly first class? |
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| How often do you purchase jewelry? |
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| Where do you purchase your jewelry? |
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| Do you purchase jewelry for yourself or for gifts? |
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| Do you purchase designer jewelry? |
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| Entertainment Demographics: |
| Are you a sports fan
or participant? |
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| Which sport? |
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| Are you a
fantasy sports
player? If so, which
sport? |
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| Do you own an iPod or
MP3 Player? |
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| Do you have broadband
Internet Access? |
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| Do you use Social Media websites? |
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| Do you have Satellite
TV? |
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| Do you subscribe to
Satellite Radio? |
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| Do you enjoy watching movies at home or at theaters? |
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| What type of movies do you enjoy? |
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| Do you read magazines? |
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| What type of magazines do you enjoy? |
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| Please select which you enjoy: |
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| Do you enjoy going to casinos? |
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| Are you a runner? |
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| How often do you run? |
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| Do you run in marathons? |
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| Which do you consider yourself? |
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| Music and eBook Buyers / Book Buyers |
| Do you own an E-Book reader? |
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| What type of reader do you own? |
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| How often do you like to Read? |
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| Which type of reading do you enjoy? |
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| Do you purchase books or music online? |
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| Travel Demographics: |
| What is your favorite kind of travel? |
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| Do you enjoy taking cruises? |
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| Do you enjoy gambling while cruising? |
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| When would you be interested in taking your next cruise? |
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| Where have you visited or would like to visit? |
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Please choose the product offers
that interest you most:
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I would like
to receive additional
information
from third party
advertisers
related to my
above interests.
Enter Security Code:
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