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* 1. First Name 

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* 2. Last Name

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* 3. Gender

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* 4. Date of Birth

Date / Time

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* 5. Ethnicity

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* 6. Do you speak Spanish?

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* 7. Home phone

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* 8. Work Phone

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* 9. Cell Phone

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* 10. Would you like to receive text notifications?

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* 11. Best phone number to reach you

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* 12. Email Address

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* 13. Housing Type 

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* 14. Home Address

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* 15. City

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* 16. State

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* 17. Zip Code

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* 18. County

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* 19. Marital Status

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* 20. Do you have children?

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* 21. Please list your children's DOB and gender

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* 22. What is your employment status?

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* 23. Are you a business owner?

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* 24. What is your Occupation/Job Title?

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* 25. What type of smartphone do you own?

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* 26. Please select the type(s) of vehicles you own.
(Select all that apply)

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* 27. What types of tobacco product(s) do you use regularly?
(Select all that apply)

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* 28. Do you have any pets? If so, what types?
(Select all that apply)

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* 29. How did you hear about us?

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