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  5. Life Style
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Name
   
 
 
 
Age
   
 
 
 
Email Address
   
 
 
 
Address
   
 
 
 
Phone Number (Landline)
   
 
 
 
Phone Number (Mobile)
   
 
 
 
Do you have the following at your home (Select all that apply)?
 
Refrigerator
 
Television
 
Washing Machine
 
Two wheeler
 
Four wheeler
 
Personal Computer
 
Laptop
 
Oven
 
DVD Player
 
Home Theater

 
 
 
Which Dish connection you have?
 
Dish TV
 
Local Setup box
 
 
 
Which Mobile subscription you use
 
Airtel
 
Idea
 
Vodafone
 
Aircel
 
BSNL
 
Uninor
 
 
 
Do you have health insurance? if yes, which insurance provider
 
Yes
 
No
 
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