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First Name
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**
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Last Name
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**
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Gender
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**
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Date Of Birth
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**
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Home or Primary Phone #:
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() - **
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Work Phone
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() - extension:
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Mobile Phone
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() -
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Email Address
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Street Address
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**
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City
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**
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State
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**
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Zip
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**
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County
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Employment Status
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Title
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Company
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Do you own a business?
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If you own a business, how many people are employed with your company including yourself?
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Education Completed
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Race/Ethnicity
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**
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Party Affiliation
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Marital Status
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Annual Household Income
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If you have children under age 18, please provide their dates of birth and genders below. If you have children over age 18, please ask them to register with us.
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Child 1
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Birthdate
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Gender
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Child 2
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Birthdate
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Gender
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Child 3
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Birthdate
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Gender
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Child 4
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Birthdate
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Gender
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Child 5
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Birthdate
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Gender
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Child 6
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Birthdate
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Gender
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Select the radio station you listen to most often:
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Select the radio station you listen to second most often:
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What is your housing type?
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Do you own a dog?
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Do you own a cat?
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Are you a vegetarian or vegan?
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Are you a sports fan? Which sports?
(Hold down the CTRL key while choosing to select multiple sports.)
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Are you right-handed, left handed or ambidextrious? (ambidextrious is EQUAL use of both hands)
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Do you drink beer?
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Do you drink wine?
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Do you drink liquor or mixed drinks?
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Do you own an ATV or four wheeler?
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If you smoke cigarettes, select the brand you smoke most often:
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Select the strength you smoke most often:
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Select the flavor you smoke most often:
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Do you smoke little cigars or cigarillos?
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Do you smoke larger cigars such as Coronas or Cubans?
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If you use moist snuff tobacco or dip, select the brand you use most often:
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Select the cut of moist snuff tobacco or dip you use most often:
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Select the flavor of moist snuff tobacco or dip you use most often:
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Do you use loose leaf Chewing Tobacco?
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Do you use Snus?
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Do you use dissolveable tobacco products such as Orbs, Sticks, Strips or compressed powdered tobacco such as Stonewall or Arriva?
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If you'd like to be considered for banking studies, please select the bank/financial institutions where you have an account.
(Hold down the CTRL key while choosing to select multiple banks.)
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If you'd like to be considered for banking studies, please select your primary bank:
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Do you exercise?
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Do you consider yourself a "Do it Yourselfer"?
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Select the store you shop for groceries most often:
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Select the store you shop for groceries second most often:
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Do you have any allergies or sensitivities to food (such as peanut butter, wheat, egg, soy, or dairy) or food additives?
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Would you consider participating in an interview in your home that may be audio and/or videotaped?
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How were you referred to our website?
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If you were referred by a friend or family member, please tell us who:
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