Thursday, July 29, 2010

Thank you for taking the time to complete this brief survey. It is through the participation of individuals like yourself that the information we collect can be used by our customers to tailor their products and services to consumers and professionals like yourself.

Please answer the questions below to the best of your ability. Leave any question blank that either doesn't apply, or you don't feel comfortable answering.

Once again, thank you and have a great day!


Which best describes you:


Personal Information
First Name:
Last Name:
Age:
Sex:
Marital Status:
How many people live in your residence?
What are the ages of your children
Child 1: Child 2:
Child 3: Child 4:
Child 5: Child 6:
Child 7: Child 8:
Child 9:
Home Phone:
Best Time to Call:
Time (HH:MM):


Work Information
Work Phone:
Best Time to Call:
Time (HH:MM):
Fax:
Email:
Best Way to Contact You:
Second Best Way to Contact You:
Least Best Way to Contact You:
Current Employment Status:
Which industry best matches yours:
Job Title:
Number of employees:
Estimated annual revenue:
Number of computers in company:
How often do you travel?
Please provide a brief job description:


Medical Information
Do you smoke?
Which of these have you been treated for in the past six months?