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First Name: Last Name: Email: Street Address: City: State: -Select One- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip/Postal Code: Gender: -Select One- Male Female Birthdate: month Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 year 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 Daytime Telephone: Evening Telephone: Cellphone: Occupation:  -------------Select One------------- Benefit Manager Clerical Consultant Engineer Homemaker Human Resources IT professional Management Meeting Planner Nurse/Medical Support Staff Physician President/CEO Sales Scientist / Research Scientist Service Worker Skilled Labor Small Business Owner Student Teacher Other Ethnicity: -------------Select One------------- Asian or Pacific Islander Black/African American Hispanic Mixed Race Native American/Alaskan Native White Some Other Race Decline to Answer Work Industry: -------------Select One------------- Accounting/Finance Advertising/PR Child/Elderly Care Computer/Software R&D Construction Education Engineering/Architecture Entertainment Financial/Banking Healthcare Information Technology Insurance Law Enformencent/Security Legal Manufacturing Marketing Marketing Research Medical Military/Government MIS/Data Processing Personal Care/Services Pharmaceuticals Real Estate Restaurant/Food Services Retail Sales - Technology Retail Sales Transport/Warehousing Travel/Lodging/Tourism Other Dare to be different? By scanning the products you buy you will make your consumer opinions heard while earning great rewards. Join the National Consumer Panel today! Yes: No: Which best describes the other members of your household, not including yourself? (If there are no other members of your household, please leave this area blank.) First: Age: ...Gender: Male Female Second: Age: ...Gender: Male Female Third: Age: ...Gender: Male Female Fourth: Age: ...Gender: Male Female Fifth: Age: ...Gender: Male Female Household Income: -------------Select One------------- Less than $20,000 $ 20,000 - $ 29,000 $ 30,000 - $ 39,000 $ 40,000 - $ 49,000 $ 50,000 - $ 59,000 $ 60,000 - $ 74,900 $ 75,000 - $ 99,999 $ 100,000 - $ 149,999 $ 150,000 + Which category best describes you? -------------Select One------------- Single, never married Married Separated/divorced/widowed Domestic partnership Are you employed? -------------Select One------------- Full time Part time Not employed Which best describes your educational level? -------------Select One------------- Completed some high school High school graduate Completed some college College degree Completed some postgrad Master's degree Doctorate, Law or Professional Join InboxDollars and get a $5 signup bonus just for joining. You will receive a confirmation e-mail. Yes: No: Join SurveySpot.com and participate in online research studies that match your interests and demographics. Yes: No: Yes: I agree to and have read the Privacy Policy, Terms and Conditions and Official contest Rules, and agree to receive special marketing promotions via email from TheNetPanel™, We Pay Your Credit Cards™, and its marketing affiliates.

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