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* 1. Contact Information: 

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* 2. Age:

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* 3. Gender: 

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* 4. What is your race or national origin?

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* 5. What best describes the area in which you live?

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* 6. What occupation/industry do you currently work in or have worked in?

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* 7. What is your total household annual income?

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* 8. Who lives in your household with you?

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* 9. What is your total PERSONAL annual income?

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* 10. What is your employment status?

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