Last name
First name
Date of birth
 
Address
Street 1
Street 2
City
State
Zip code
 
Phone numbers
Home
Work
Cell
 
Type of Internet connection
E-mail address
E-mail address (again for verification)
 
Occupation
Industry in which you work
 
Marital status
 
Education
 
Ethnicity If other...
 
Household income before taxes
 
Children living at home
Male age     Female age
Male age     Female age
Male age     Female age
Male age     Female age
 
Grandchildren living in the
IMMEDIATE
Des Moines area
Male age     Female age
Male age     Female age
Male age     Female age
Male age     Female age
 
What health issues do you suffer from?
Arthritis High Blood Pressure
Asthma Migraines
Diabetes    Ulcers
Heart Disease
Do you smoke? Yes    No     If so, what brand?
Other medical issues
 
Are you a registered voter? Yes   No
If so, what party? Democrat     Republican     Independent     Other
 
What is you favorite FM radio Station? If other, enter it here
 
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