Personal Information
Last Name
*
First Name
*
Email
*
Password
*
In order to modify your profile in the future, please create a password with 5 or more characters.
Home Phone (xxx)-xxx-xxxx
N/A
Office Phone (xxx)-xxx-xxxx
N/A
Cell Phone (xxx)-xxx-xxxx
N/A
Street
*
City
*
State/Province
Select from the list
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
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
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Ontario
Prince Edward Island
Quebec
Saskatchewan
*
Zip
*
Gender
Select from the list
Male
Female
*
Which of the following ranges includes your age?
Select from the list
6-11
12-14
15-17
18-20
21-24
25-29
30-34
35-44
45-54
55-64
65+
*
Date of Birth (mm/dd/yyyy)
*
Into which ethnic category do you fall?
Select from the list
African American
Asian
Caucasian
Hispanic
Native American
Multi-racial
Other
*
Other
Marital Status
Select from the list
Married
Divorced
Single
Widowed
Significant Other
*
Occupation (specify industry)
Select from the list
Accounting
Advertising
Aerospace
Agricultural
Apparel
Appliances
Architecture
Art
Automotive
Aviation
Banking
Beauty
Bio Medical
Broadcasting
Brokerage
Business Services
Carpentry
Catering
Chemical
Child Care
Clothing
Communications
Community Services
Computers
Construction
Consulting
Cosmetics/Skin Care
Customer Service
Delivery/Messengers
Design
Development & Research
Direct Mail
Distribution
Education
Electronics
Employment
Engineering
Entertainment
Environmental
Export/Import
Fashion
Finance
Fire/Rescue
Fitness
Flowers
Food Service
Fund Raising
Furniture
Garment
Government
Health Care
Health Insurance
Health/Beauty Aids
Heating/Air Conditioning
Hospitality
Import/Export
Insurance
Interior Decorating
Jewelry
Journalist
Landscaping
Law Enforcement
Law/Legal
Library
Livery
Manufacturing
Marketing
Media
Medical
Medical Equipment
Mental Health
Military
Mining
Motion Picture Industry
Music
Nursing
Pharmaceutical
Plumbing
Printing
Property Management
Public Relations
Public Utility
Publishing
Real Estate
Recreation
Recycling
Religion
Research & Development
Residential
Restaurant
Retail
Sales
Sanitation
Science
Security
Shipping/Delivery
Social Services
Software Development
Software Sales
Sporting Goods
Supplies
Technical
Telecommunications
Textile
Tourism
Toy
Transportation
Travel
Trucking
Utilities
Waste Management
Wholesale
Other
*
Other
Occupation (Title)
*
Occupation (Type)
Select from the list
Full Time
Part Time
Student
Not Working
Retired
Housewife
*
Education
Select from the list
High School
Some College
Graduate School
College Graduate
Trade School
*
Children:
Do you have any children?
YES
NO
Date of Birth (mm/dd/yyyy)
Gender
Male
Female
Date of Birth (mm/dd/yyyy)
Gender
Male
Female
Date of Birth (mm/dd/yyyy)
Gender
Male
Female
Date of Birth (mm/dd/yyyy)
Gender
Male
Female
Date of Birth (mm/dd/yyyy)
Gender
Male
Female
Date of Birth (mm/dd/yyyy)
Gender
Male
Female
Total household income
Select from the list
Under $30,000
$30,000 - $39,999
$40,000 - $49,999
$50,000 - $59,999
$60,000 - $74,999
$75,000 - $99,999
$100,000 - $149,999
$150,000 - $199,999
$200,000 +
*
Do you own or rent your home?
Select from the list
Own
Rent
Other
Other
Pets:
Select from the list
Dog
Cat
Other
No Pets
Other
# of business trips
# of leisure/personal trips
Vehicle Information
Vehicle 1 Ownership/leasing
Select from the list
Own
Lease
Do not own or lease a vehicle
Vehicle 1 Year
Vehicle 1 Make
Vehicle 1 Model
Vehicle 2 Ownership/leasing
Select from the list
Own
Lease
Do not own or lease a vehicle
Vehicle 2 Year
Vehicle 2 Make
Vehicle 2 Model
Based on previous question, what is your vehicle (1) type
Select from the list
Car-sedan (4-door)
Car-coupe (2-door)
Minivan
SUV
Pickup Truck
Other
Other
Does any member of your household plan to buy or lease a new vehicle(s) in the next 12 months?
YES
NO
Telecommunications
Local phone service provider
Select from the list
AT&T
MCI
Verizon
Other
Other
Long distance phone service provider
Select from the list
AT&T
MCI
Verizon
Other
Other
If you have a cellular phone, who is your primary provider?
Select from the list
AT&T
Sprint
Cingular
T-Mobile
Nextel
Verizon
Other
Do not have
Other
Do you receive a monthly bill or purchase prepaid minutes for your cellular phone?
Select from the list
Monthly bill
Purchase prepaid minutes
N/A
Which of the following do you own? (multiple select)
Desktop Computer
Laptop
Pocket PC
Camcorder
CD Burner / Writer
Digital Camera
DVD Player
MP3 Player
Standard TV
Flat Screen TV
Gameboy
Playstation
X-Box
Gamecube
Plasma TV
Cellular Phone
Big Screen
Tivo
Reply PVR
Which internet search engine do you use most often?
Select from the list
AOL
Google
MSN
Yahoo
Other
Do not connect to the Internet
Other
What type of Internet connection do you have at home?
Select from the list
Do not connect to the Internet
Cable
Direct TV-Link
DSL
Modem/dial-up
Wireless
Other
Other
Your e-mail provider is:
Select from the list
A paid for (e-mail) service (i.e., AT&T/AOL)
A free (e-mail) service (i.e., Hotmail, Yahoo)
None
Which of the following portable wireless devices do you have which connect to the Internet?
Select from the list
Cell phone w/internet access
Pager
Blackberry
Handheld PC
PDA
Other
Iphone
Ipad
None of these
Other
Have you purchased any products or services over the Internet in the past year?
YES
NO
Financial Information
Do you or does anyone in your household currently own any (multiple select):
Stocks or Equities Corporate
Municipal Bonds
Treasury Bonds
Does anyone in your household use a:
Select from the list
Discount Broker
Full Service Broker
Do not use any Broker
Do you trade, buy or sell stocks, bonds, or transact any other type of investments on-line?
YES
NO
Which of the following active Credit Cards do you have and use?
American Express
Select from the list
None
Regular
Gold/Platinum
Blue
Centurion
Optima
Corporate
Diners Club
Select from the list
None
Regular
Gold/Platinum
Corporate
Visa
Select from the list
None
Regular
Gold/Platinum
Corporate
Debit
MasterCard
Select from the list
None
Regular
Gold/Platinum
Corporate
Debit
Discover
Select from the list
None
Regular
Gold/Platinum
Preferences
What types of non-alcoholic beverages do you drink? (multiple select)
Bottled Water
Regular Coke
Diet Coke
Non-Alcoholic Beer
Fruit Drinks
Regular Pepsi
Diet Pepsi
Coffee
Energy Drinks
Other Regular Soda
Other Diet Soda
Tea
Other
What types of alcoholic beverages do you drink? (multiple select)
Champagne
White Wine
Vodka
Domestic Beer
Gin
Tequila
Imported Beer
Rum
Whiskey
Red Wine
Scotch
Liqueurs/Cordials
Premium Malt Beverages
Clear Malt Beverages
Other
Which of the following do you use on a regular basis? (multiple select)
Allergy Medication
Eye Drops
Vitamins
Herbal Remedies
Prescription Medication
Do you currently take medication for any chronic medical conditions such as cholesterol, heart disease, diabetes, blood pressure, arthritis, allergies?
YES
NO
If yes, what medical conditions?
Do you smoke cigarettes?
YES
NO
What Brand?
What type?
Select from the list
Menthol
Non-Menthol
Lights
Ultra-Lights
100s
Are they:
Select from the list
Discount Brands
Regular Brands
Other
Are you a registered voter?
YES
NO
What political party are you affiliated with?
Select from the list
Democratic
Republican
Independent
None