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1.
What is your FIRST and LAST name?
(Required.)
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2.
What is the best phone number for us to contact you on?
(Required.)
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3.
What is your gender?
(Required.)
Male
Female
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4.
What is your age?
(Required.)
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5.
What City and State do you currently reside in?
(Required.)
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6.
Which of the following best describes your ethnic background?
(Required.)
African American
Asian
Caucasian
Hispanic/Latino
Native American
Other
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7.
Which of the following best describes your marital status?
(Required.)
Single
Married or Living with partner
Divorced, Separated, Widowed
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8.
Do you have any children 17 or younger living in your household?
(Required.)
Yes
No
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9.
Which of the following best describes your employment situation?
(Required.)
Employed full-time
Employed part-time
Self-employed
Homemaker
Student
Retired
Not employed
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10.
What is the highest level of education you have had the opportunity to complete?
(Required.)
Some High School or less
High School/GED
Some College
Trade/Technical School
College Graduate
Some Post College
Advanced Degree
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11.
What industry do you work in?
(Required.)