Customer Begins

Thank you for agreeing to take our survey. All the answers you provide are anonymous and confidential.

This survey consists of 2 pages and should take no longer than 3 minutes to complete on average.

THANK YOU

1. Please indicate your gender.

	Male
	Female

2. Which category includes your age?

3. Do you have children?

	Yes
	No

How many of your children currently live in your household?

4. What best describes your martial status?

5. What best describes your employment status?

6. What best describes your level of education?

7. Which of the following ranges include your personal annual income before taxes?

8. Ethnicity Required Question

9. Interest In Your Free Time & About You Required Question

10. Contact You

First Name Required Question

Last Name

Title

Company Name

Street Address

Apt/Suite/Office

City

State

Postal Code Required Question

Country

Email Address Required Question

Phone Number

Fax Number

Mobile Phone

URL

	Under 18
	18-24
	25-34
	35-44
	45-54
	55-64
	65 or above

	Single, Not Married
	Married
	Living with partner
	Separated
	Divorced
	Widowed

	Employed full time
	Not employed
	Retired
	Student
	Homemaker

	Some high school
	High school graduate or equivalent
	Trade or Vocational degree
	Some college
	Associate degree
	Bachelor's degree
	PhD

	Under $20,000
	$20,000 - $29,999
	$30,000 - $39,999
	$40,000 - $49,999
	$50,000 - $69,999
	$70,000 - $99,999
	$100,000 - $149,999
	$150,000 or more
	Prefer not to answer

	Asian/Pacific Islander
	Black/African-American
	Caucasian
	Hispanic
	Native American/Alaska Native
	Other/Multi-Racial
	Decline to Respond