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* 1. Full Name

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* 2. E-Mail Address

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* 3. Phone number to reach you

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* 4. What is your age?

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* 5. Where do you live?

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* 6.  What is your current employment status?

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* 7. Which of the following best describes your ethnic background?

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* 8. What is the highest level of education you have completed?

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* 9. What is your marital status?

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* 10. Which of the following is true?

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* 11. Are you head of your household?

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* 12. What is your annual household income before taxes?

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