1. What is your name?

2. What is the best phone number for us to contact you on?

3. What is your gender?

4. What is your age?

5. Which of the following best describes your domestic status?

6. Do you have any children under 18 living at home with you?

7. What was the last grade of school you completed?

8. What is your current employment status?

9. Which of the following best describes you total annual household income before taxes?

10. What industry, if any, do you currently work in (if not employed please type NONE below)?

11. What is your ethnicity?

12. What state/city do you currently reside in?