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First Name:

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Last Name:

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Home Phone:

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What’s your email address?

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May we call you at work?

If yes, what is the number?

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If you have a cell phone and we can call you on it, please give us that number:

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Date of Birth: 

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Gender:

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Marital Status:

Ethnic Background:

Highest level of education completed:

Are you employed:

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Party Affiliation:

Do you own a cat, dog or other pet?

Do you smoke?

Do you have a Computer for home use?

Are you Online at home?  What is your access?

Do you suffer from any of the following? (Specify which; Hold the <ctrl> key down to select/unselect multiple responses)

What is your residence?

Home Address

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City

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State

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Zip

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County

Please list the Date of Birth and Gender of each child in your household under the age of 18:

Child 1

First Name:

Birthdate:
   

Gender:

Child 2

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Birthdate:
   

Gender:

Child 3

First Name:

Birthdate:
   

Gender:

Child 4

First Name:

Birthdate:
   

Gender:

Child 5

First Name:

Birthdate:
   

Gender:

Child 6

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Birthdate:
   

Gender:

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