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	First Name:*	Middle Initial:	Last Name:
Address:
Zip Code:*
Phone: (home)*		(work)
E-mail:

Sex:*

Male

Female

Date of Birth (mm/dd/yy):*

Ethnic Background:*

African-American Caucasian Hispanic Asian Other

Marital Status:*

Married Single Divorced Separated Widowed

Occupation:

Employer:

Years of education completed:*	Do you own pets?		Do you smoke?		Do you own your own home?
	Yes No		Yes No		Yes No

Do you have children living at home?*

Yes

No

What are their names, sex and birth dates?

		(mm/dd/yy)
1.	Male: Female:	Date of Birth:
2.	Male: Female:	Date of Birth:
3.	Male: Female:	Date of Birth:
4.	Male: Female:	Date of Birth:

Do you have any friends who might be interested?

Name	Phone

In which of the following ranges does your total household income fall?*

Less than $10,000	$10,000-$20,000	$20,000-$30,000	$30,000-$40,000
$40,000-$50,000	$50,000-$60,000	$60,000-$70,000	$70,000-$80,000
$80,000-$90,000	More than $90,000

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