Sign Up Form
CURRENT APPLICATION FOR U.S. RESIDENTS ONLY.
First: Middle: Last: Address: (Example: 321 Temple Terr Brooksville FL 3667) (No one will call, Example: 555-888-0900) Phone: Work Phone: Fax: Email: (Example: user@isp.com) Occupation: (Example: Teacher) Favorite Site: (optional) (Example: www.website.com) Age: (Example: 35) Date Of Birth: (Example: 5/6/78) Average Income: (Do not use $ or comma or decimal points) Family Members In Household: Gender: (M/F) (Example: 3) Do You Have A Website? (This may disqualify you) Yes If not - leave blank. If So What Is The URL? Where Do You Use The Internet? (check all that apply) Coffee Shop School/College Home Friend/Relatives House Work Library/Public Terminal How Long Have You Used The Internet? Less Than A Year Three Or More Years More Than A Year Ethnicity: Questions? African American Germanic Italian Hispanic Native American Native Islander Asian Caucasian Other Religion: (optional) Christian Wicca Catholic New Age (Transcendentalism etc) Hindu Buddhism Muslim Orthodox (Russian or Greek) Judaism Other
First: Middle: Last: Address: (Example: 321 Temple Terr Brooksville FL 3667)
Family Members In Household: Gender: (M/F) (Example: 3) Do You Have A Website? (This may disqualify you) Yes If not - leave blank. If So What Is The URL? Where Do You Use The Internet? (check all that apply) Coffee Shop School/College Home Friend/Relatives House Work Library/Public Terminal How Long Have You Used The Internet? Less Than A Year Three Or More Years More Than A Year Ethnicity: Questions? African American Germanic Italian Hispanic Native American Native Islander Asian Caucasian Other Religion: (optional) Christian Wicca Catholic New Age (Transcendentalism etc) Hindu Buddhism Muslim Orthodox (Russian or Greek) Judaism Other
Privacy Statement: All information collected will only be used for statistics and measuring, all names and personal information will be kept strictly confidential. In no manner will the information be sold or used for direct marketing purposes.
