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Date:
Survey City:
Salutation:
First Name:
Last Name:
Address:
 
City:
State:
Zip:
E-mail:
Home Phone: ( ) -
Cell Phone: ( ) -
Work Phone: ( ) -
Sex: Male Female
Birthday:    Age:
Marital Status:
Spouse's birth year:
Do you have children? Yes No
Please complete sex
and age information:






Male Female Birth Year
Male Female Birth Year
Male Female Birth Year
Male Female Birth Year
Male Female Birth Year
Race:
Religious Preference:
Yearly Household
Income:

Last Level of
School completed:

Employment:
Industry:
Role in Company:
Job Title / Occupation:
Spouse's
Job Title / Occupation:

What pets do you have?
(Check all that apply)
No Pets
Dog
Cat
Fish
Bird
Other - please specify
Residence:
Do you speak Spanish? Yes No
Do you use tobacco? Yes No
Which of these tobacco products
do you currently use?
(Check all that apply)
Menthol Cigarettes
Non-menthol Cigarettes
Cigars and/or Pipe Tobacco
Loose Leaf Tobacco
Snuff / Chewing Tobacco
Do you drink alcohol? Yes No
Which of these alcohol products
do you drink?
Beer
Miller/Light/MGD/Chill/Hamm's/Etc.
Budweiser/Light/Select/Ice/Busch/Etc.
Corona/Pacifico/Modelo/Etc.
Sol/Dos Equis/Tecate/Etc.
Wine
Merlot/Cabernet/Zinfandel/Pinot
Gewürztraminer/Chardonnay/Riesling
Hard Liquor
Absinthe
Brandy
Rum
Schnapps
Tequila
Vodka
Whisky
Are you registered to vote? Yes No
Political Affiliation:
What kind of computer do you have?
PC
Mac
Unknown
None
Do you subscribe to... Cable TV
Satellite TV
FiOS TV
Which video game system(s) do you play?
Microsoft XBox Microsoft XBox 360 Nintendo DS / DS Lite
Nintendo GameCube Nintendo Wii Sony Playstation 2
Sony Playstation 3 PSP Other
Household Vehicles (including motorcycles):
Make = Manufacturer (Ford, Toyota, Mercedes, Hyundai, Nissan, etc.)
Model = Version of Car.  (Explorer, Mustang, Corolla, etc.)
(For each vehicle, all fields are required.)
 
Make
 
Model
Year

Purchased
 
Driven By


Make

Model
Year

Purchased

Driven By


Make

Model

Year

Purchased

Driven By


Make

Model
Year

Purchased

Driven By
Please list any hobbies or
interests you have.
(e.g. Boat owner, Scrapbooking, etc)