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Your e-Mail Address
     

Your First Name
     

Your Last Name
     

Gender
     Male
     Female

In what month were you born?
     Jan
     Feb
     Mar
     Apr
     May
     Jun
     Jul
     Aug
     Sep
     Oct
     Nov
     Dec

In what year were you born? (Four-digit year such as "1965")
     

What city do you live in?
     

What state do you live in?
     

What is your Zip Code?
     

Which of the following best describes the ethnic group in which you belong—
     African American
     American Indian or Alaska Native
     Asian
     Spanish/Hispanic/Latino
     White or Caucasian
     Native Hawaiian or Other Pacific Islander
     Other
     Prefer Not to Say
     Don't know

Are you currently—
     Employed Full Time
     Employed Part Time
     Not Employed

Occupation
     

What is your approximate annual household income before taxes?
     Please Choose One
     Less than $25,000
     $25,000 to $49,999
     $50,000 to $74,999
     $75,000 to $99,999
     $100,000 to $149,999
     $150,000 or higher
     Prefer Not To Say
     Don't Know

What kind of Internet access do you have?
     Dial Up
     DSL
     Cable
     T1
     Other
     Don't Know

Have you read and do you agree to our Statement of Agreement
     Yes
     No

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