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Name
   
 
 
 
* Age group
 
0-15
 
16-20
 
21-25
 
26-30
 
31-35
 
36-40
 
41-45
 
46-50
 
51-60
 
Over 60
 
 
 
* Gender
 
Male
 
Female
 
Do not disclose
 
 
Size of household
0 1 2 3 4 5 Over 5
* Adults (18 and up)
* Children (below 18)
 
 
 
* Annual household income
 
0-50,000
 
50,000–100,000
 
100,000–150,000
 
150,000–200,000
 
Over 200,000
 
 
Please provide the following information about your primary residence
0 1 2 3 More than 3
# of bedrooms
# of closets
# of car spaces in garage
# of floors
 
 
 
* Occupation (select all that apply)
 
Employed full-time
 
Employed part-time
 
Self-employed
 
Student
 
Unemployed

 
 
 
* 1
   
 
 
 
* 1
   
 
 
 
2
   
 
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