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First Name:	Initial:	Last Name:
Phone: (example: xxx-xxx-xxxx)	E-mail: (example: myname@host.com)
Street Address:
City:	State: Choose AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY	Zip:
Age: Choose one Under 18 18-23 24-29 30-35 36-41 42-47 48-53 54-59 60 & Above	Credit Card(s): Select all that apply Visa Mastercard American Express Discover/Novus None
Income: Choose one Under $10,000 $11,000 - $21,000 $22,000 - $32,000 $33,000 - $43,000 $44,000 - $54,000 $55,000 - $65,000 $66,000 - $76,000 $77,000 - $87,000 $88,000 - $98,000 $99,000 - $109,000 $109,000 & Above	Interests: (Select all that apply.) Select all that apply Art Animals Cooking Education Environment Exercising Gardening Movies/TV Music Politics Reading Theater Traveling Shopping Sports
Have you made a purchase by mail in the last 3-12 Months? Choose one Yes No
Have you made an online purchase in last 6 months? Choose one Yes No

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