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All Questions marked with an asterisk (*) are required:

*First name:

*Last name:

*E-mail:

*Date of birth:

Home phone:

( )

Work phone:

( )

Cell phone/pager:

( )

*Home Zip Code:

Occupation:

Employer:

*Gender:

Marital status:

Highest level of education:

Are you of Hispanic or Latino origin (ethnicity)?



If Hispanic, what is your Latin-American
country  of origin?

Which of the following best describes your race?

National background:

What country were you born in?

Employment status:

Total household  income:

Political party:

Do you have  pets?

Dog
Cat
Other

Which of the following is your current Cable/TV Service Provider?

Do you consume alcoholic beverages?

If yes, which of these do you drink  regularly?

Beer
Brandy/Cognac
Gin
Rum
Scotch
Tequila
Vodka
Wine
Cordials/Liqueurs
Whiskey/Bourbon

Do you smoke cigarettes?

If you smoke please tell us what brand you prefer:

How often do you exercise?

once a month or less
2-3 times/month
once a week
2-3 times/week
4-6 times/week
7 times a week

Have you ever been diagnosed with any medical conditions (e.g. cholesterol, diabetes, GERD, etc)?
Select up to 5. Hold down the <ctrl> key to make multiple selections.

What medications, if any, do you take?
Select all that apply. Hold down the <ctrl> key to make multiple selections.

Do you wear any of the following?

glasses
contacts
both
neither

Please list all of the automobiles currently driven in your household:

Car 1:

Make:

Model:

Year:

Own Lease

Car 2:

Make:

Model:

Year:

Own Lease

Car 3:

Make:

Model:

Year:

Own Lease

Car 4:

Make:

Model:

Year:

Own Lease

Do you have any children under the age of 18 living at home with you?

Yes
No

If yes, what are their genders and dates of birth?

Boy
Girl

Birthdate

Boy
Girl

Birthdate

Boy
Girl

Birthdate

Boy
Girl

Birthdate

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