First Name *
Last Name *
How did you hear about TAi-Tampa? *
Select ALL that apply. Please scroll down to view additional selections. Hold the Control <Ctrl> key while clicking to select multiple languages. To remove a language, hit <Ctrl> while clicking again.
Chatroom/Bulletin Board
Craigslist
Convention / Booth
Flyer
Friends/Family/Co-Worker
Mail
MySpace Advertisement
Newspaper Ad
Radio Ad
Street Address
City *
Alberdale
Altamonte Springs
Anita Maria
Apollo Beach
Apopka
Arcadia
Astatala
Auburndale
Avon Park
Babson Park
Balm
Bartow
Bay Pines
Bayonet Point
Bayway Tierra Verde
Belleair
Belleair Beach
Belleair Bluffs
Beverly Hills
Blue Island
Boca Raton
Bowling Green
Bradenton
Brandon
Brooksville
Carrollwood
Casselberry
Champions Gate
Chicago
Chuluota
Cincinnati
Clearwater
Clearwater Beach
Clermont
Coconut Creek
Crystal Beach
Crystal Springs
Dade City
Davenport
Davis Island
Delta
Dover
Duette
Dundee
Dunedin
Durant
Ellenton
Englewood
Eustis
Floral City
Forrest Hills
Fort Lauderdale
Fort Meade
Fort Myers
Fruitlane Park
Gainsville
Geneva
Gibsonton
Glades
Gulf Port
Gulfport
Haines City
Harbour Island
Heathrow
Hernando
Hernando Beach
Hinsdale
Holiday
Holly Hill
Homasassa
Hudson
Indian Rocks Beach
Indian Shores
Inverness
Jacksonville
Jasper
Kathleen
Kenneth City
Kissimmee
Labelle
Lake Alfred
Lake City
Lake Forest
Lake Hamilton
Lake Helen
Lake Mary
Lake Panasoffkee
Lake Suzy
Lake Wales
Lakeland
Land O Lakes
Largo
Lavelle
Lehigh Acres
Libertyville
Lithia
Lithia Spring
Longboat Key
Longwood
Lutz
MacDill AFB
Madeira Beach
Maitland
Mango
Masaryk Town
Miami
Millerville
Mulberry
Mussel Shoals
N Redington Beach
Nancy
Nashviille
New Berry
New Orleans
New Port Richey
Nocatee
Nokomis
Oakland
Ocala
Ocoee
Odessa
Oldsmar
Ona
Orlando
Oviedo
Ozona
Palm Harbor
Palmetto
Pasadena
Pensacola
Pinellas County
Pinellas Park
Placida
Plant City
Polk City
Port Charlotte
Port Richey
Punta Gorda
Reddington Beach
Redington Beach
Redington Shores
Ridge Manor
Riverview
Ruskin
Safety Harbor
Saint Cloud
Saint Leo
Saint Petersburg
Salem
San Antonio
Sanford
Sanibel
Sarasota
Satellite Beach
Sebring
Seffner
Seminole
Seminole Heights
Shady Hills
Six High Acres
Somerville
South Pasadena
Spring Hill
St Leo
St. Cloud
St. Pete
St. Petersburg
St. Petersburg Beach
Sun City Center
Sunset City Center
Tampa
Tarpon Springs
Tavares
Temple Terrace
Terre Haute
Thonotosassa
Tierra Verde
Titusville
Town & Country
Treasure Island
Trinity
University Park
Vallejo
Valrico
Venice
Wauchula
Wauwach
Webster
Weeki Wachee
Wesley Chapel
Wheeling
Willowbrook
Wimauma
Winter Garden
Winter Haven
Winter Park
Winter Springs
Withalacoochee
Yankeetown
Ybor
Zephyrhills
Zolfo Springs
Other
Other
State
Colorado
Alabama
Alaska
Arizona
Arkansas
California
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennesee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconson
Wyoming
Zip Code *
33503
33508
33509
33510
33511
33527
33529
33530
33534
33547
33548
33549
33550
33556
33558
33559
33563
33564
33565
33566
33567
33568
33569
33570
33571
33572
33573
33575
33583
33584
33586
33587
33592
33594
33595
33598
33601
33602
33603
33604
33605
33606
33607
33608
33609
33610
33611
33612
33613
33614
33615
33616
33617
33618
33619
33620
33621
33622
33623
33624
33625
33626
33629
33630
33631
33633
33634
33635
33637
33647
33650
33651
33652
33653
33654
33655
33656
33657
33659
33660
33661
33662
33663
33664
33665
33668
33669
33670
33672
33673
33674
33675
33677
33679
33680
33681
33682
33683
33684
33685
33686
33687
33688
33689
33690
33694
33695
33697
33698
33701
33702
33703
33704
33705
33706
33707
33708
33709
33710
33711
33712
33713
33714
33715
33716
33717
33725
33728
33729
33730
33731
33732
33733
33734
33736
33737
33738
33740
33741
33742
33743
33744
33747
33753
33754
33755
33756
33757
33758
33759
33760
33761
33762
33763
33764
33765
33766
33767
33769
33770
33771
33772
33773
33774
33775
33776
33777
33778
33779
33780
33781
33782
33784
33785
33786
33801
33803
33804
33805
33807
33809
33810
33811
33812
33813
33815
33823
33825
33827
33830
33834
33837
33838
33841
33844
33849
33850
33859
33860
33865
33868
33872
33873
33880
33881
33884
33890
33896
33897
33898
33907
33911
33934
33935
33936
33946
33950
33952
33954
33955
33957
33975
33980
33981
33982
34201
34203
34205
34207
34208
34209
34210
34211
34212
34216
34221
34222
34224
34226
34228
34230
34231
34233
34234
34236
34237
34238
34239
34241
34242
34243
34266
34269
34275
34277
34292
34368
34431
34436
34442
34446
34448
34451
34452
34458
34465
34471
34472
34473
34474
34476
34479
34498
34589
34601
34602
34603
34604
34606
34607
34608
34609
34610
34613
34614
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34619
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34621
34622
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34624
34625
34626
34630
34637
34638
34639
34640
34641
34648
34650
34652
34653
34654
34655
34656
34659
34660
34667
34668
34669
34671
34674
34677
34681
34682
34683
34684
34685
34688
34689
34690
34691
34695
34697
34698
34705
34711
34731
34741
34744
34759
34760
34761
34763
34771
34772
34787
34963
35549
35564
35635
35772
35920
36404
37072
37573
37604
37752
45233
53624
60035
60045
60048
60090
60134
60514
60521
60610
60615
60634
60640
60643
60660
85254
94591
Other
Other
County
Charlotte
Citrus
Desoto
hardee
Hendree
Hernando
Highlands
Hillsborough
Lake
Lutz
Manatee
Marion
Orange
Pasco
Pinellas
pinn
Polk
Sarasota
Seminole
Home Phone (including area code, please) *
Work Phone
Cell Phone
E-mail Address *
(enter "NA" if you don't have e-mail)
Date of Birth *
Select the Month:
January
February
March
April
May
June
July
August
September
October
November
December
Day:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
(Sorry, but you must be over 18)
Gender *
Male
Female
Classification
Consumer
Consumer/Medical
Consumer/Professional
Medical
Physician
Professional
Do you own or rent your current residence?
Other
Own
Rent
Type of Residence:
Apartment
Condominium
Cooperative Apt
N/A
Private Home
Annual Household Income (before taxes)
*
<15
15-19999
20-24999
25-29999
30-34999
35-39999
40-44999
45-49999
50-54999
55-59999
60-69999
70-79999
80-89999
90-99999
>100000
Unknown
Highest Level of Education Completed: *
Tech/Vocational School
Less than HS Graduate
High School Graduate/GED
Some College
College Grad.
Post Grad.
Unknown/refused
Marital Status *
Divorced/Separated
Married
Single
Unknown/Refused
Widowed
Ethnicity *
African American
Asian, Pacific Islander
Caucasian
Hispanic
Hispanic-Spanish Only
Multi-racial
Native American
Other
Unknown/Refused
Employment Status *
Disabled / Unemployed
Full time
Not working
Part time
Retired
Self employed
Unemployed
Unknown
How are you registered to vote?
Democrat
Independent
Republican
Unknown/Refused
Occupation
Home Health Care O
Professional Nanny O
*N/A O
Account Executive O
Accountant O
Accounting Clerk O
Accounts Payable O
Accounts Receivable O
Actor/Actress O
actress O
Adjuster O
Administrative Assistant O
Administrative O
Administrative Support O
Administrator O
ADULT P
Advertising O
Advisor O
Aerospace O
Aide O
Air Force O
air O
Air Traffic O
Airlines O
Allergy P
Analyst O
Anestheologist M
Anesthesia Tech M
Anesthesiologist P
Animal/Pet Grooming O
apparel O
Appraiser/Adjuster O
Arborist O
Architect O
Army O
Artist O
Assembler O
assistant O
assistant teacher O
Asst. Manager O
Asst. Principal O
Astrologer O
Athlete O
Atmospheric Physicist O
Attorney O
Auctioneering O
Audiologist M
Auditor O
Author O
AUTO BODY O
Automotive O
Avon Sales O
Baby Sitter O
BANK O
bank teller O
Banker O
Barber O
Bartender O
Beautician O
Beautician/Cosmetologist O
Behavioral Analyst O
Bilingual Aide O
Boat Captain O
Bond Writer O
booking agent O
Bookkeeper O
Bookseller O
BREWERY WORKER O
Broker O
Builder O
business owner O
Burglar Alarm Systems O
Bus Rider O
Business Law O
Business Mgr. O
Business O
Busser O
Buyer O
cable installer O
Cake Designer O
car inspector O
Cardiologist P
CARDIOVASCULAR P
Care Giver O
Carpenter O
CARPET CLEANER O
Case Management O
Case Manager O
Cashier O
Catering O
Charitable Organization O
Chef/Cook O
child care O
Childcare O
Chiropractor M
City Planner O
Civil Engineer O
Claims Processor O
Claims Rep. O
Clergy O
Clerical O
CLERK 3 POLICE DEPT. O
Clerk O
Clerk/Secretary O
Clinical Coordinator O
Clinical Research Assoc. M
Closer O
Clothing O
CNA M
Coaching O
Coding O
Collections O
COMMUNICATIONS O
Community Relations O
Community Service Officer O
Compliance Specialist O
Computer Analyst O
computer consultant O
Computer Engineering O
computer operator O
Computer Programmer O
Computer Sales O
Computer Software O
COMPUTER SPECIALIST O
COMPUTER TECHNICIAN O
COMPUTER M
Concierge O
Concrete Statuary O
construction O
Construction Worker O
Consultant O
Consumer Affairs O
Contractor O
Control Analyst O
Controller O
COOK O
coordinator O
Copywriter O
Corporate Liaison O
correctional O
cosmetologist P
COUNSELOR O
Courier O
Court Reporter O
CPA O
Credit Analyst O
Credit Collections O
Credit Manager M
Credit Union O
criminal record searcher O
Curator O
custodial cleaning O
Customer Service O
Dancer O
DATA ENTRY O
Data Processing O
Day Care O
Decorator O
Defense Consultant O
Deli O
Delivery O
Demonstrator O
Dental Assistant M
Dental Hygienist M
Dentist M
dentist P
Deputy Sheriff O
Dermatologists P
Designer O
Detective O
Developer O
Diabetes Educator
Dietitian O
Direct of Services O
Director O
Disabled O
DISC JOCKEY O
Dispatcher O
Dispatcher P
Distributor O
DISTRICT MGR. O
DOG GROOMER O
domestic violence counselor O
Doorman O
Draftsman/Designer O
Driver O
Drivers Lic Examiner O
Dry cleaning O
E.N.T. P
Echocardiographer P
Editor Assistant O
Editor O
Education O
Education Specialist O
Electrician O
Electronic Technician O
Electro physiologist P
emergency medicine P
Emergency Services O
Employment Specialist O
endocrinology P
Engineer O
Entertainer O
Entertainment Industry O
Environmental Manager O
EQUIP. OPERATOR I O
Equipment operator O
ER P
Estimator O
Examiner O
Executive Secretary O
Executive Assistant O
Executive O
Export Agent O
Exterminator O
Fabric Technician O
factory O
Family Planning Clinic M
family practice - DO P
family practice - MD P
family practice P
Family Support Worker O
Farming O
Federal Agent O
Field Personnel O
Finance O
Financial Analyst O
Financial Representative O
Financial Services O
Fireman O
Fitness Instructor O
Flight Attendant O
Florist O
Food Service O
Foreman O
FORENSIC PSYCHIATRY P
Forensic Specialist O
Framer O
FREELANCE MARKETING O
Fundraiser O
Funeral Home O
furniture O
gas station O
Gastroenterologists P
general practice - DO P
general practice P
general surgeon P
Geo Tech O
GERIATRIC P
gift basket business O
Glass Manufacturing O
Government O
Graphic Artist O
Grocery/Food Manufacture O
Guidance Counselor O
Gyn/Onc P
Gynecology P
Health Benefits Coordinator O
Health Care O
Health Management M
hearing aid specialist O
Hearing Master - Courts O
Heating/ Air Conditioning O
hematology/oncology P
HISTOLOGY M
Home Builder O
Home Improvement O
HOME O
Home School O
horticulture P
Host/Hostess O
Hotels O
House Cleaner O
House Painter O
Housekeeper O
Housewife O
Human Resources O
Hydrogeologist O
Illustrator O
IM Analyst O
Industrial Hygienist O
infectious disease P
Infertility P
Information Analyst O
Information Tech. O
Inspector O
Installer O
Instructor O
Insurance adjuster O
Insurance O
Insurance Rep. O
interior design P
INTERNAL MEDICINE P
Internet O
Interpreter P
INVESTIGATOR O
Investments O
investor O
IRS O
Janitor O
Jeweler O
journalism O
Judge O
L.N.A O
laboratory assistant M
Laboratory Manager M
Laborer O
Laminator O
Land Agent O
Landlord O
Landscaper/Gardener O
Law Enforcement O
Leasing Agent O
LEC Coordinator O
Legal Assistant O
Librarian O
License Practical Nurse O
Lifeguard O
Lighting O
Liquor Promotions O
Lithographer O
Loan Officer O
Locksmith O
logistics O
LPN M
Lumber Trader O
Machinist O
Mail Man O
Mail Room O
Maintenance O
Major League Sports O
Make-Up Artist O
Managed Mental Health O
Manager/Supervisor O
Manufacturer O
map tech O
maritime O
MARKETING &SPONSORSHIP O
MARKETING ASSISTANT O
marketing coordinator O
marketing intern O
marketing O
Marketing Rep O
Mechanic/Machinist O
mechanical designer O
Media O
Medical Assistant O
Medical Biller M
Medical Device O
Medical Management M
Medical O
Medical Records O
Medical Technician O
Medical Transcriptionist M
Mental Health O
Merchandiser O
Merchandising Rep. O
Message Therapist O
meteorologist O
Meter reader O
Microbiologist O
Midwife M
Military O
Minister O
MIS O
Model O
Monitor O
Mortgage Broker O
Moving and Storage O
Musician/Singer O
n/a P
NA O
Nanny O
Naturalist O
Navy P
Negative Retoucher O
Network Analyst O
Network Engineer O
Network Manager O
Neurologist P
Newspaper O
Notary O
Nurse M
Nurse's Aide O
Nursing O
Nutritionist/Dietician M
ob/gyn P
Obstetrics P
Office Clerk O
office equipment O
OFFICE MANAGER O
office worker O
Officer O
oncology P
Operations O
Operator O
Ophthalmologist Technician O
Ophthalmologist M
Optician M
Optometrist M
ORTHOPEDIC SURGEON P
Orthopedics P
Otorhinolaryngologist P
outdoor themed events O
OWNER O
Packer/Shipper O
pain management P
Painter O
PARA PROFESSIONAL O
Paralegal O
Paramedic O
Paramutual (Horse Racing) O
Parking Attendant O
Pathology P
PATIENT ADVOCATE M
Patient Coordinator O
Payroll Administrator O
Pediatrics P
PEDORTHIST O
Personal Agency O
Personal Fitness O
Personnel Asst. O
Personnel/Human Resources O
Pharmacist M
pharmacist oncology M
Pharmacy Technician M
Pharmaceuticals Mfg O
PHLEBOTOMIST O
Photographer/Cameraman O
Photography O
Physical Ed. Teacher O
Physical Therapy O
Physician asst. O
Physician M
Pilot O
Planner O
plastic surgeon P
Plumber O
plumbing supplies sales O
Police Officer O
Postal Worker O
President O
Pricing Coordinator O
Priest O
Principal O
Printer/Lithographer O
Printing Co O
Private Investor O
PROBATION OFFICER O
Processor O
Produce Buyer O
Production O
PROFESSOR O
Program Coordinator O
Programmer O
Project Coordinator O
Project Manager O
Projectionist O
property manager O
Proposal Writer O
Proprietor/Owner O
Psychiatrist M
Psychiatrist P
Psychologist M
Psychologists P
Public Relations M
Publishing O
pulmonary P
Purchasing O
psychic O
quality Control O
Radio/TV Broadcasters O
Real Estate Appraiser O
Real Estate O
Realtor O
Receiving Clerk O
Receptionist O
Recorder O
Recovery Agent O
Recreation O
RECRUITER HEALTHCARE O
Recruiter O
referee O
Referral Specialist O
Registered Nurse M
Religion O
religion O
Repair O
Research Analyst O
Research Director M
research vegetable spec. O
Researcher O
Reservationist O
Resident Assistant O
Respiratory Therapist M
Restaurant consultant O
Restaurant O
Retail Department Store O
Retail O
Retired O
rheumatology P
RN-ICU M
Roofer O
Safety Specialist O
Sales Assistant O
SALES MANAGER O
Sales O
Sales Rep O
SALES TELEMARKETING O
Salesperson O
Sanitation & Safety O
scheduling O
School Aide O
School O
Scientific Research O
Scientists O
seafood Market O
Seaman O
seamstress O
Secretary O
Security Guard O
Self-Employed O
Senior Data Technician O
Service clerk O
Service Mgr. O
Service Representative O
SHERIFFS OFFICE O
Shipping O
Site Manager O
Social Worker O
Software Support O
Specialist O
Speech Therapist O
sport protection specialist O
sport retail O
staff assistant O
STAFFING COORDINATOR O
state government O
stay-at-home mom O
Stock Broker O
Stocker O
Student O
Stylist O
Substitute teacher O
SUPERVISOR O
Support Staff O
Surgical Assistant O
Swimming Pool Supplies O
System Administrator O
Systems Analyst O
Systems Engineer O
Tailor/Seamstress O
Talk Show Host O
Tanning O
Tax Administrator O
Taxi Driver O
Teacher Assistant O
Teacher O
Tech Support O
Technical Analyst O
Technical Writer O
Technician O
TECHNOLOGY ASSISTANT O
TELECOMMUNICATIONS O
Telemarketing O
Telephone O
Telephone Operator O
Telerecruiter O
Telesales O
Temp. Job O
tenant coordinator O
Theatre O
Therapist O
Title Insurance O
Toll Collector O
Toxicologist M
Trader O
TRAFFIC ENFORCEMENT O
Traffic Engineer O
Trainer/Instructor O
transcriptionist M
Transportation O
Travel Agent O
truck driver O
Truss Fabrication O
Tutor O
U.S. Customs Service O
UNDERWRITER O
United States Army O
University O
UPDATE O
Urban Planner O
UROLOGY P
USPS O
Utilities O
Verifier O
VESSEL OPERATIONS O
Vet Assistant O
Vet Technician O
Veterinarian M
Vice President O
Volunteer O
Waiter/Waitress O
Warehouse Mgr O
warehouse O
Water Analysis O
Water Filtration O
Water Management O
water plant operator O
Web Applications O
Website Designer O
weight inspector O
Welder O
wood O
Word Processing O
Writer O
x-ray tech O
YMCA Front Desk O
Zookeeper O
Industry
*N/A
Accounting
Accounting Consulting
Administrative Assistant
Advertising
Aerospace
Aerospace Research
Agriculture
Air Force
Air Freshener
Airconditioning
Airlines
Airport
Alcohol/Drugs
Amusement/Entertainment
Annuities
ANTIQUES
Apartment Rental
Apartments
Apparel
Appliances
Aquariums
AQUATICS
Architect
Armored Car
Artwork
Audio/Visual
Audiology
Auto Parts/Retail
Automation
Automotive
Aviation
Bakery
Banking
Banking/Debt
Benefits
Beverages
Blood Bank
Boating
Body Piercer
Bond Writer
Books
BREWERY
Broadcasting
Broker
Business
Cabinetry
Car Dealership
Carpet
Catalog Fullfillment
CELLULAR SERVICE
Ceramic Tile
Charity
Chemicals
Child Care
Children & Family Services
China/Silverware
Church
City
City Of Tampa
Civil Service
Cleaning
Clerk
CLOTHING
Collections
Commercial
Communications
Comp. Hardware&Software
Computer Software
COMPUTERS
Construction
Consulting
Contractor
Convenience Store
Copiers
Corp,Travel International
Corrections
Cosmetics
Cosmetology
Counseling
Country Club
County Sheriff's Office
Courier
Credit
Cruise
Customer Service
Dance/Exercise
Data Communication
Data Comunication
Data Entry
Day Care
Death Care
Decorating
Demolition
DENTAL
Department Of Corrections
Department Stores
Design
Dining Services
Direct Mail
Dispatch
Display Technology
Drug Stores
Dry Cleaning
Education
Electrical
Electrical Engineering
Electronics
Elementary School
Employment
Engineering
Entertainment
Entertainment Corporation
Environment
Equipment Delivery
Equipment Leasing
Exports
Eyeglasses
Fabrics
Factory Work
Fashion
FAST FOOD
Federal Court
Fertilizer
Film
Finance
Fire Department
Fitness
Floor Coverings
Florist
Flowers/Shrubs
Food
Fragrance Compounds
Fragrances
Fuel
Fundraising
Funeral
Furniture
Gardening
Gasoline
General Motors
Geo-Tech
GIRL SCOUT COUNCIL
Glass Wholesaler
Government
Graphic Arts
Grocery
GTE
Hair Care
Hardware/Tools
Hazodous Waste
Health Care
Health Club
Health Insurance
Heavy Equipment
Hillsborough County
Home Furnishing
Home Improvement
Home Maker
Home Repair
Horse Breeding
Hospital
Hospitality
Hotel/Motel
Houseware
Housing
Human Resources
Human Services
Immigration Service
Income Taxes
Industrial
Industrial Air Conditioning
Information Services
Insurance
Interior Design
Internet
Investigation
Investment
Janitorial
Jewelry
Job Placement
Journalist
Judicial
Kindergarten
Kitchenware
Labor
Laboratory
Landscaping
Laundry/Dry Cleaning
Law
Law Enforcement
Leasing
Legal
Lighting
LIQUOR
Literacy
Lottery
LPN
Machinery
Magazine
Mailing
Maintence
Manager
Manufacturer
Marine
Marketing
Material Handling Equipment
MECHANIC
MECHANICAL
Medical
Medical Technician
Medicare Unit
Mental Health
Merch. Assoc
Metals
MIDDLE SCHOOL
Military
Mining
Minister
Modeling
Models/Hobbies/Crafts
Mortgage
MOTOR HOMES
Movers
Multi-Media
Municipal
Music
Mutual Funds
N/A
Navy
Network Comunications
Networking
Newspaper
Nightclub
Non-Profit
Nursery
Nursing
Nursing Home
Office Manager
Office Supplies/Equipment
OIL
Operations
OPTICAL
Orthopedics
Packaging
Paint Equipment
Painting
Paper Products
Parking
PATHOLOGY
Pawn
Perscription Lenses
Pest Control
Pets
Pharmaceuticals
Pharmacy
Photography
Planning Commission
Plastics
Plumbing
Police Offcer
Postal Service
Power
Printing
Private
Private Law Firm
Professional
Property Management
Psychology
Public Accounting
Public Relations
Publishing
Radioilogy
Railroad
Real Estate
Recreation
Recruitment
Refrigeration Service
Religion
Renovation
Rental Company
Rentals
Repro Graphis
Res./Comm. Land Development
Reservations
Restaurant
Retail
Retirement Communities
Revenue
ROOFING
Sales
Salons
School
Science
SDP
Secretary Services
Security
Security Bonds
Security Systems
Self Employed
Service
Sewage
Ship Building
Shipping
SIGN SALES
Signs
Skin Care
Social Security
SOCIAL SERVICES
Software
Solid Waste
Space Industry
Sports
Staffing Services
Stage Manager
State
Steel
STOCKS
STOCKS And BONDS
Storage
Supermarkets
Supervisor
SUPPORT FOR PRODUCTION
Swmming Pools
Teacher
Technology
Telecommunications
Telemarketing
Telephone
Television
Temporary Industries
Textiles
Theater Hospitality
Theatre Hospitality
Tobacco
Toll Collector
Tourism
Toys
Trailer Park
TRANSPORTATION
Travel
TREE SERVICE
Trucking
U.S. Postal Service
University/College
Unknown
USPS
Utilities
Veteranarian
Video
Waitress
Warehousing/Storage
Water Manegment
Water Supply
Weight Management
Wholesaling
Windows And Doors
Workmans Comp
Writing
ZOOKEEPER
How many employees are in your company?
1
1001-4999
100-500
10-14
15-20
21-25
2-5
26-49
5000+
501-1000
50-99
6-9
How many children under the age of 18 are in your household? *
None
1
2
3
4
5
6
7
8
9
Please give information about the children in your household
Gender Birth Date
First Child
Male
Female
Select the Month:
January
February
March
April
May
June
July
August
September
October
November
December
Day:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
Second Child
Male
Female
Select the Month:
January
February
March
April
May
June
July
August
September
October
November
December
Day:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
Third Child
Male
Female
Select the Month:
January
February
March
April
May
June
July
August
September
October
November
December
Day:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
Fourth Child
Male
Female
Select the Month:
January
February
March
April
May
June
July
August
September
October
November
December
Day:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
Fifth Child
Male
Female
Select the Month:
January
February
March
April
May
June
July
August
September
October
November
December
Day:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
Sixth Child
Male
Female
Select the Month:
January
February
March
April
May
June
July
August
September
October
November
December
Day:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
Which languages other than English, do you speak fluently?
Select all that apply. Please scroll down to view additional selections. Hold the Control <Ctrl> key while clicking to select multiple languages. To remove a language, hit <Ctrl> while clicking again.
Arabic
Chinese
Croatian
Dutch
French
German
Hebrew
Italian
Japanese
Korean
Latin
Mandarin
Norwegian
Portugese
Romanian
Russian
Sign Language
Spanish
Swedish
Vietnamese
Which of the following medical conditions do you suffer from?
Select all that apply. Please scroll down to view additional selections. Hold the Control <Ctrl> key while clicking to select multiple languages. To remove a language, hit <Ctrl> while clicking again.
Acid Reflux
Acne
ADD/ADHD
Allergies
Alzheimers
Anemia
Anxiety
Arthritis
Asthma
Athlete's Foot
BiPolar
Bronchitis
Cancer
Carpel Tunnel
Cerebral Palsy
Colitis
COPD
Crohns Disease
Cystic Fibrosis
Dentures
Depression
Diabetes
DVT
Eating Disorder
Eczema
Emphysema
Epilepsy
Erectile Dysfunction
Fibromyalgia
Frequent Urination
Gerd/Acid Reflux
Glaucoma
Hay Fever
Headaches
Hearing Disorders
Heart Disease
Hemophilia
Hepatitis
Herpes
High Blood Pressure
High Cholestrol
Hypertension
Hypoglysemia
Hypothyroidism
IBS
Incontinent
Indigestion
Insomia
Kidney Disease
Leukemia
Liver Condition
Lupus
Migraines
Multiple Sclerosis
Myopia
Narcolepsy
Obesity
Osteoarthritis
Osteopenia
Osteoporosis
Overactive Bladder
Parkinsons
Prostate
Psoriasis
Reproductive Disease
Respiratory Disorders
Restless Leg Syndrome
Seizures
Sickle Cell Disease
Sinusitis
Skin Condition/Disease
Sleep Problems
Stress
Stroke
Tacnacardia
Thyroid
Ulcers
West Nile Virus
Which medical conditions do any of your immediate family members suffer from?
Select all that apply. Please scroll down to view additional selections. Hold the Control <Ctrl> key while clicking to select multiple languages. To remove a language, hit <Ctrl> while clicking again.
Acid Reflux
Acne
ADD/ADHD
Allergies
Alzheimers
Anemia
Anxiety
Arthritis
Asthma
Athlete's Foot
BiPolar
Bronchitis
Cancer
Carpel Tunnel
Cerebral Palsy
Colitis
COPD
Crohns Disease
Cystic Fibrosis
Dentures
Depression
Diabetes
Eating Disorder
Eczema
Emphysema
Epilepsy
Erectile Dysfunction
Fibromyalgia
Frequent Urination
Gerd/Acid Reflux
Glaucoma
Hay Fever
Headaches
Hearing Disorders
Heart Disease
Hemophilia
Hepatitis
Herpes
High Blood Pressure
High Cholestrol
Hypertension
Hypoglysemia
Hypothyroidism
IBS
Incontinent
Indigestion
Insomia
Kidney Disease
Leukemia
Liver Condition
Lupus
lymphoma
Migraines
Multiple Sclerosis
Myopia
Narcolepsy
Obesity
Osteoarthritis
Osteopenia
Osteoporosis
Overactive Bladder
Parkinsons
Prostate
Psoriasis
Reproductive Disease
Respiratory Disorders
Restless Leg Syndrome
Seizures
Sinusitis
Skin Condition/Disease
Sleep Problems
Stress
Stroke
Tacnacardia
Thyroid
Ulcers
West Nile Virus
Which of the following alcoholic beverages do you consume?
Select all that apply. Please scroll down to view additional selections. Hold the Control <Ctrl> key while clicking to select multiple languages. To remove a language, hit <Ctrl> while clicking again.
Beer
Bourbon
Brandy
Champagne
Gin
Liquers
Mixed Drinks
Rum
Scotch
Tequila
Vodka
Whiskey
Wine
Wine Cooler
What type of beer do you drink?
Select all that apply. Please scroll down to view additional selections. Hold the Control <Ctrl> key while clicking to select multiple languages. To remove a language, hit <Ctrl> while clicking again.
Dark
Domestic
Dry
Ice
Import
Light
Microbrew
Regular
Who is your cell phone provider/carrier?
Alltel
AT&T
Boost Mobile
Cellular One
Cingular
MCI
Metro PCS
Nextel
Nokia
Qwest
Sprint
T-Mobile
Trac fone
Verizon
Virgin Mobile
Voice Stream
Which of the following pets do you own?
Select all that apply. Please scroll down to view additional selections. Hold the Control <Ctrl> key while clicking to select multiple languages. To remove a language, hit <Ctrl> while clicking again.
None
Bird
Cat
Dog
Fish
Hamster
Horse
Lizard
Monkey
Rabbit
Snake
Turtle
Other
Do you have cable television?
Yes
No
Do you have satellite television?
Yes
No
Do you eat organic foods/drinks?
Yes
No
Do you own your home?
Yes
No
Do you smoke cigars?
Yes
No
Do you smoke cigarettes?
Yes
No
Which brand of cigarettes do you smoke, if any?
Select all that apply. Please scroll down to view additional selections. Hold the Control <Ctrl> key while clicking to select multiple languages. To remove a language, hit <Ctrl> while clicking again.
100's
alpine
Benson and Hedges
Camels
Capris
Dural
full flavored
Genric
Kools
lights
Marlboro
Newport
Parliament
salem
ultralights
winston
Are you a member of the AARP?
Yes
No
Do you have a home based office?
Yes
No
Do you travel out of town for work?
Yes
No
Housing Type
Apartment
Condo
House
Other
Please tell us about the main vehicle you drive:
Year:
1985 or earlier
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Make:
Acura
Audi
Bentley
BMW
Buick
Cadillac
Chevy
Chrysler
Datsun
Dodge
Ford
Geo
GMC
Harley-Davidson
Honda
Hummer
Hyundai
Infiniti
Isuzu
Jaguar
Jeep
Kia
Landrover
Lexus
Lincoln
Mazda
Mercedes
Mercury
Mitsubishi
Nissan
Oldsmobile
Plymouth
Pontiac
Porsche
Rolls-Royce
Saab
Saturn
Subaru
Suzuki
Toyota
Volkswagen
Volvo
Yamaha
Purchased New or Used:
New
Used
What type of vehicle is it?
Car
Motorcycle
RV
SUV
Truck
Van