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Complete the registration form below:

First Name			note: we cannot send payments without accurate contact information
Last Name
Your Email Address

Street Address
Address 2 (if needed)
City

State (Use "Other" if not in USA)

Country

Zip Code

The following information allows us to match you with the needs of our clients, so that you receive the most relevant survey offers and they receive the information they desire.

Are you male or female?
Male
Female

What is your current marital status?
Single (never been married)
Married
Separated
Widowed
Divorced
Domestic Partner

How would you describe your current employment status?
Employed full-time
Employed part-time
Self-employed
Retired
Unemployed
A homemaker
A student
Disabled
Other

What is the highest level of education you yourself completed?
Grade school or less
Some high school
High school graduate
Vocational, trade school, or technical training beyond High School
Some college
College graduate
Post-graduate studies or degree (beyond college degree)
Professional degree

In what year were you born?

Which one of the following categories includes your household's gross annual income? (yes, you may select "refused," but it may diminish your chances of being selected for survey and focus group participation)
Under $25,000
$25,000 to just under $35,000
$35,000 to just under $45,000
$45,000 to just under $55,000
$55,000 to just under $75,000
$75,000 to $100,000
Over $100,000
Refused

Do you currently: (Check all that apply)
		Own a business?
		Operate a business from your home?
		Own an Internet based business?

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