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Mailing Information

Name:

Address:

City:

State:

Zip:

Phone:

Email:

Demographic Information

Gender:
Male  Female

Date of Birth:
(format of mm/dd/yyyy)

Education:

Occupation:

How often do you dine out?:
1 - 2 times per week 3 - 4 times per week 5 + times per week not very often

Are You:
Married  Single

Home Ownership:
Own  Rent  Live with Parents

Number in Household:
1 2 3 4 5 6+

Number Of Children:
0 1 2 3 4 5 6+

Household Income:
$15,000 to $25,000 $26,000 to $30,000 $41,000 to $50,000 $51,000 to $60,000 $61,000 to $70.000 $71,000 to $80,000 $81,000 to $90,000 $91,000 to $100,000 $101,000 to $125,000 $126,000 to $150,000 $151,000 to $175,000 $176,000 to $200,000 over $200,000

Do you use coupons?:
Yes  No

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