Elliott Benson - Sacramento Market Research

Full Name:
Home Phone:
Work Phone:
Email Address:
Home Address:

Birthdate:
Gender:	Male Female
Marital Status:	Single Married Divorced Live-Together Widowed
Household Information:	Rent Own
If own, year bought:
Gross Household Income (before taxes):	Under $20K $20-35K $36-50K $51-75K $76+
Education:	Some H.S. H.S. Grad Some College College Grad Post Grad
Occupation:
Industry:
Ethnic Background:
Party Affiliation:
Hobbies:
Children Age (Mo./Yr.) and Sex:	Male Female Male Female Male Female
Tell us about your spouse/significant other:
Full Name:
Work Phone:
Email Address:
Birthdate:
Gender:	Male Female
Education:	Some H.S. H.S. Grad Some College College Grad Post Grad
Occupation:
Industry:
Ethnic Background:
Party Affiliation:
Hobbies:
Children Age (Mo./Yr.) and Sex:	Male Female Male Female Male Female
Please indicate if you own any of the following:
	Computer
	Internet
	Cellular Phone
	Boat
	RV
	Satellite