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First name Gender female male   Last name       Home phone Date of birth Month January February March April May June July August September October November December   Work phone Extension   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 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 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   Cell phone Ethnicity African American American Indian Asian Bi-Racial Caucasian Hispanic Latino Other   Fax Education 0-8th Grade Some High School High School Grad./GED Some College   Email Household income < 10000 10000-19999 20000-29999 30000-39999 40000-49999 50000-74999 75000-99999 100000-149999 150000-199999 200000-249999 250000-299999 300000-399999 400000-499999 500000+   Home Address Type of housing Rent - Apartment Rent - Condo Rent - House Rent - Other Own - Apartment Own - Condo Own - Co-op Own - House Own - Other Own - Town House Rent - Co-op Rent - Town House   City       State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia 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 Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming       Zip

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