| First Name* |
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Last Name* |
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| Street Address* |
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| City* |
, OH |
Zip* |
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| Home Phone* |
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Cell Phone |
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| E-mail* |
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Sex* |
Male Female |
Date of birth*
(MM/DD/YYYY) |
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Smoker? |
Yes No |
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| Employment status* |
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Occupation |
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| If you're a teacher, please indicate what grade level you teach |
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| Race |
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Education |
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| Income |
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Homeowner? |
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| Political Affiliation |
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Marital Status |
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| Please list the date of birth (MM/DD/YYYY) and sex of each child under age 18 living in your household. |
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Male Female |
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Male Female |
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Male Female |
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Male Female |
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Male Female |
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Male Female |
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| By checking the box below, you agree to add your personal information to Opinion Centers America's respondent database. You agree to be contacted through any means submitted on this form, and that your answers are accurate. Your privacy is our number one concern and this list will never be sold to, accessed by, shared with, or given to anyone outside of Opinion Centers America. If you do not check the box, your information will not be accepted. |
| Add me! |
