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First Name
Last Name
Age	Please select one under 18 18-25 26-29 30-39 40-49 50-59 60 or over
Gender	female male
Education	Please select one grammar/middle school high school diploma some college bachelor's degree graduate degree
Marital Status	Please select one single married divorced other
Children in Household	Please select one 0 1 2 3 4+
Address
City
Country	Please select country Afghanistan Albania Algeria Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegowina Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Cote D'Ivoire Croatia Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faroe Islands Fiji Finland French Guiana French Polynesia Gabon Gambia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guatemala Guinea Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Republic of Kuwait Kyrgyzstan Latvia Lebanon Lesotho Liberia Liechtenstein Lithuania Luxembourg Macedonia, The Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Martinique Mauritania Mauritius Mexico Mongolia Montserrat Morocco Mozambique Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Reunion Romania Rwanda Saint Lucia Saint Vincent and the Grenadines San Marino Sao Tome and Principe Saudi Arabia Senegal Yugoslavia Seychelles Sierra Leone Singapore Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Taiwan Tajikistan Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay United States Uzbekistan Vanuatu Venezuela Wallis and Futuna Islands Yemen Zaire Zambia Zimbabwe
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ZIP or Postal Code
Home Phone
Occupation	Please select one accounting/finance executive/senior management professional/managerial technical/engineering administrative/secretarial sales/marketing/advertising customer service/support college/university faculty college/university student k-12 student writer/journalist homemaker retired currently not employed other
Company Name
Organization Type	Please select one internet-related services television/radio/print publishing printing/graphics entertainment advertising/media/public relation marketing/communications sales software development k-12 education college/university education government finance/banking/accounting architecture/engineering/construction medical services legal services wholesale/retail transportation/utilities consulting nonprofit agriculture/forestry manufacturing/distribution other
Company Size	Please select one under 10 employees 10-99 employees 100-499 employees 500-999 employees 1000-9999 employees 10000+ employees
Work Phone
Primary Net Connection	Please select one at home at work at home business at K-12 school at college/university at library/public terminals other
Internet Experience	Please select one under 6 months 6 months - 1 year 1-2 years 3+ years