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Rank the following colours:
Blue
Green
Yellow
Red
 
 
 
Which job do you have?
 
Doctor
 
Lawyer
 
Accountant
 
Other
 
 
 
 
What types of credit cards do you have (Select all that apply)?
 
Visa
 
Mastercard
 
American Express
 
Discover
 
Diners Club

 
 
 
How often do you conduct surveys?
 
 
 
Comments/Suggestions:
   
 
 
 
What is your date of birth?
 
 
Contact Information
First Name : 
Last Name : 
Address 1 : 
Address 2 : 
City : 
State : 
Zip : 
Phone : 
Email Address : 
 
 
How satisfied are you with the following:
Very Unsatisfied Unsatisfied Neutral Satisfied Very Satisfied
Website
Customer Service
Overall
 
 
How satisfied are you with the following:
Very Unsatisfied Unsatisfied Neutral Satisfied Very Satisfied
Website
Customer Service
Overall
 
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