Preliminary Questionnaire 1. Basic Information 20% of survey complete. Question Title * 1. Contact Information (Required.) Name: * Company: Address: * Address 2: City/Town: * State: * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: * Country: Email Address: * Phone Number: * Question Title * 2. Alternate contact info Alt. email Mobile Business ph. Fax Twitter Facebook LinkedIn Question Title * 3. Preferred Method of Contact (select all that apply) (Required.) Home Phone Mobile Phone Business Phone Email Alt. Email Question Title * 4. How did you hear about us? (Required.) Website FPA NAPFA Attorney/Accountant Referral Friend/Family Referral Publication/Periodical Print Advertisement Other Referred by? Question Title * 5. D.O.B. Date of Birth Date Spouse/Partner Date of Birth Date Question Title * 6. What is your Marital Status? Married Single Divorced Widowed Civil Union Domestic Partnership Other Other (please specify) Question Title * 7. Spouse/Partner's Full Name Question Title * 8. Number of Dependent Children: Question Title * 9. Number of Other Dependents for Whom You are Financial Responsible Next