*First Name
*Last Name
*Gender
Male
Female
*Date of Birth
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Before 1925
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
Ethnicity
African American
American Indian, Eskimo
Asian, Pacific Islander
Caucasian
Hispanic
Other
Do you speak Spanish?
Yes
No
Home Phone
Work Phone
Cell Phone
*Best Phone number to reach you.
Home Phone
Work Phone
Cell Phone
*Email Address
Home Address
*City
*State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Marital Status
Divorced/Separated
Living with Significant Other
Married
Single
Widowed
What is your highest level of education?
0-8th Grade
Advanced Degree
Associate Degree
College Grad.
High School Grad./GED
Some College
Some High School
Trade School
What is your combined/total household income before tax?
under 15,000
15-24,999
25-34,999
35-49,999
50-74,999
75-99,999
100-149,999
150,000+
Refuse
Please Select what hand you write with and use most often.
Left Hand
Right Hand
Ambidextrous (Both)
Child Gender and Date of Birth
Child 1 Gender
Male
Female
Birthdate
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Child 2 Gender
Male
Female
Birthdate
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Child 3 Gender
Male
Female
Birthdate
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Child 4 Gender
Male
Female
Birthdate
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Child 5 Gender
Male
Female
Birthdate
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Child 6 Gender
Male
Female
Birthdate
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
What's your employment Status?
Full Time Employment
Homemaker
Part Time Employment
Retired
Self Employed
Student
Unemployed
What is your Occupation/Job Title?
What type(s) of computer(s) do you own?
(Select all that apply. Hold down the <Ctrl> key while clicking to make multiple selections)
Android
Compaq
Dell Streak
HP
Ipad
Kindle
Mac
Tablet
Windows Desktop
Windows Lap Top
Who is your internet provider?
550 Access
550 Access HiSpeed
AT&T
Basic ISP
Cable One
Cablevision
CenturyLink High-Speed
Charter Communications
Charter Internet Lite
Clear Wire
Comcast
Comcast High-Speed Internet
Copper Net
Cox Communications
Cricket
DataJack
Mediacom
NetZero 3G
NetZero DSL
PeoplePC
Qwest DSL
RCN
Sprint
Time Warner Cable - Broadband Internet
T-Mobile
Toast.Net
Toast.net Internet Service
TotalUSA
TurboUSA
Verizon
Other
Who is your cable provider?
Adelphia Communications
AT&T
Bright House Metworks
CableOne
Cablevision
Century Link
Charter
Comcast
Cox
DirectTV
Dish Network
HughesNet Satellite
Insight
Mediacom
RCN
Suddenlink
Time Warner Cable
Wildblue Satellite
Other
Who is you home landline service provider?
AT&T
Cavelier
CenturyLink
CenturyTel
Cincinnati Bell
Consolidated
Cyford Communications
DPI
Embarq
Frontier
Lingo
Qwest
Sage Telecom
TDS
Verizon
Vonage
Windstream
Other
Who is your cell phone provider?
AT&T
Boost Mobile
Cricket
Metro PCS
Sprint/Nextel
T-Mobile
TracFone
U.S. Cellular
Verizon
Virgin Mobile
Other
What is the make and model of your cell phone?
Which of the following genres of PC games do you currently play?
(Select all that apply. Hold down the <Ctrl> key while clicking to make multiple selections)
*None
Action/Adventure Games
Alternative or Arcade Style Sports
Castleville
Cityville
Facebook
Farmville
First Person Shooter
Frontierville
Massive Multiplayer Online
Music Games
Role Playing Games
Sim Social
Strategy Games
Third Person Shooter
Traditional or Simulation Style Sports
Please select the type(s) of vehicle(s) you own.
(Select all that apply. Hold down the <Ctrl> key while clicking to make multiple selections)
Convertible
Coupe
Minivan
Motorcycle
Sedan
Sports Car
SUV
Truck
Other
What type(s) of tobacco product(s) do you use regularly?
(Select all that apply. Hold down the <Ctrl> key while clicking to make multiple selections)
*None
Cigarettes
Cigars
Smokeless Chewing Tobacco
Other
Do you own any pets if so what type(s)?
(Select all that apply. Hold down the <Ctrl> key while clicking to make multiple selections)
*None
Bird
Cat
Dog
Ferret
Fish
Gerbil
Hamster
Parakeet
Rabbit
Snake
Tortoise
Which of the following types of beverages do you drink/purchase regularly?
(Select all that apply. Hold down the <Ctrl> key while clicking to make multiple selections)
*None
Beer
Bottled Water
Coffee
Energy Drinks
Liquor
Soft Drinks
Sports Drinks