Last name
First name
Date of birth
Address
Street 1
Street 2
City
State	AL AK AR AZ CA CO CT DC DE FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VI VT VA WA WV WI WY
Zip code
Phone numbers
Home
Work
Cell
Type of Internet connection	None High-speed cable High-speed DSL High-speed satellite Dial-up
E-mail address
E-mail address	(again for verification)
Occupation
Industry in which you work
Marital status	Single Married Significant Divorced Widowed
Education	Didn't graduate High school High school Some college College Degree Post grad
Ethnicity	African American Asian Caucasian Hispanic Native American Other If other...
Household income before taxes	less than $30,000 $30,000 to $39,999 $40,000 to $49,999 $50,000 to $59,999 $60,000 to $74,999 $75,000 to $99,999 $100,000 to $149,999 $150,000 and up
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
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?	KJMC 89.3 KJJY 92.5 KIOA 93.3 KGGO 94.9 KHKI 97.3 KMXD 100.3 KSTZ 102.5 KLTI 104.1 KDRB 106.3 KKDM 107.5 Other If other, enter it here
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