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<br /> <br /> <br /> <br /> <br /> <br /> Cwnnrn,vzmerr aamldac~w c~urvo <br /> <br /> <br /> Please complete as much of this survey as possible, and leave blank the items that you don't care to or do <br /> not apply. Check as many boxes as apply. Feel free to elaborate, adding more pages as needed (refer to <br /> questions by number). Remember to sign and date the release at the end of the form. Thank you. <br /> <br /> 1) Name <br /> <br /> 2) Date of birth Place of birth <br /> 3) Marital Status: ? Single ? Married ? Divorced ? Cohabiting <br /> <br /> 4) Do you have any children? ? Yes ? No. How many? <br /> <br /> 5) Ages? <br /> 6) Your level of education: ? High school ? Some college ? College graduate ? Post <br /> graduate. Degrees: Major <br /> <br /> <br /> 7) Credentials, certifications or licenses <br /> <br /> <br /> <br /> 8) Occupation / vocation / special skills: <br /> <br /> <br /> 9) How do you make a living? <br /> <br /> <br /> 10) Job Title: <br /> 11) Do you make hiring or purchasing decisions for your company? ? Yes ? No. <br /> <br /> 12) Household Income bracket ? Up to $15,000 ? $15-30,000 O $30- 50,000 <br /> ? $50-100,000 ? $100,000+ ? $500,000+ ? Over $1,000,000 <br /> <br /> 13) What are your interests? E.g., Sports, music, politics, sciences, hobbies, social or <br /> cultural activities. What do you do for fun? <br /> <br /> <br /> <br /> <br /> 14) What is your ethnic /cultural/ religious affiliation? <br /> <br /> <br /> 15) Do you give to charities? ? Yes ? No. What type? <br />