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It's important to supply
accurate and complete information. All fields with asterisks
are required and invalid information
may disqualify your submission.
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First Name: * |
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Last Name: * |
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E-mail Address: * |
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Street Address: |
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City: |
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Province: |
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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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Marital Status: |
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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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Household Information: |
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Do you own or rent your
residence? |
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Dwelling Type: |
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Household Income: |
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Educational Information: |
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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: |
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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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Behavior/Lifestyle Demographics: |
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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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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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Investing/Insurance Demographics: |
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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: |
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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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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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Entertainment Demographics: |
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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 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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Please select which you enjoy: |
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Do you enjoy going to casinos? |
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Travel Demographics: |
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What is your favorite kind of travel? |
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Do you enjoy taking cruises? |
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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.
Yes
No
Enter Security Code:
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