CONSUMER DATABASE FORM

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*Referred by Call from Gilmore Email Family/Friend Flyer Newspaper Internet Search Update Information Other If an individual referred you, please give us their name. *First Name *Last Name *Address *City County *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 *Home Phone Cell Phone Work Phone Email May we notify you of future studies via email? Yes No *Date of Birth Month January February March April May June July August September October November December   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 2007 2006 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 *Gender Male Female *Ethnicity African American Asian, Pacific Islander Caucasian Hispanic Native American Other

*Marital Status Divorced/Separated Married Partnered Single Widowed Unknown/Refused *Education Less Than High School High School Grad/GED Some College Associates degree 2 Yr Trade Degree/Cert. College Grad Master's Degree PhD       CHILDREN       First Name DOB Month January February March April May June July August September October November December   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 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Gender Male Female First Name DOB Month January February March April May June July August September October November December   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 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Gender Male Female First Name DOB Month January February March April May June July August September October November December   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 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Gender Male Female First Name DOB Month January February March April May June July August September October November December   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 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Gender Male Female     *Employment Full Time Part Time Student Homemaker Retired Unemployed Are You Self Employed? Yes No Job Title:(only if working Full Time or Part Time) Employer: Industry: Accounting Administration Advertising Aerospace Agriculture/Farming Airline Animal Care Architecture Art Automotive Banking Biotech Chemical Child Care Communication Computer Construction Consulting Contracting Cosmetic Crafting Delivery Dental Design Distribution Education Electrical Electronics Employment Engineering Entertainment Environmental Equipment Fashion Film Financial Fitness Food and Beverage Retail Food and Beverage Service Freight Gaming Government Graphics Grocery Healthcare High Tech Hospitality Hotel Insurance Landscape Legal Manufacturing Marketing Media Military Non-Profit Phamaceutical Photo Printing Public Service Publishing Real Estate Religion Research Restaurant Retail Security Service Shipping Software Sports Technology Telecommunications Tourism Transportation Travel Utilities Wholesale Other If you are in an industry that is not in the list, please enter it here: Number of Employees (Locally): Less than 10 10-49 50-99 100-499 500-999 1000-1999 2000+ Household Income Less than $10,000 $10-20K $20-30K $30-40K $40-50K $50-75K $75-100K $100-125K $125-150K $150K+ Home Own Rent Live w/Parents Pets (Select all that apply. Hold down the Ctrl key to make multiple selections) Cat Dog Other None Music Genre (Select all that apply. Hold down the Ctrl key to make multiple selections) Adult Contemporary Alternative Blues/RB Classic Rock Classical Country Jazz News Talk Oldies Rap/Hip Hop Religious/Gospel Rock Spanish Sports Talk Top 40/Pop Other If you like a genre that is not in the list, please enter it here: Alcohol usage (Select all that apply. Hold down the Ctrl key to make multiple selections) Beer Liquor Non-alcoholic Wine None Tobacco usage (Select all that apply. Hold down the Ctrl key to make multiple selections) Chewing Tobacco Cigarettes Cigars Nonsmoker Pipe Vegetarian Yes No Coffee Usage Yes No Tea Usage Yes No Medical Insurance Yes No Corrective Lens Yes No Do you or does anyone in your household have a chronic medical condition? (Select all that apply. Hold down the Ctrl key to make multiple selections) Anxiety Asthma Arthritis Cancer Depression Diabetes Heart disease Hepatitis B Hepatitis C High Blood Pressure High Cholesterol HIV/AIDS MS Weight Loss Surgery Other None If you have a medical condition that is not in the list, please enter it here: Do you own/use any of the following? (Select all that apply. Hold down the Ctrl key to make multiple selections) Blackberry Cable TV Cell phone Desktop computer Digital camcorder Digital camera High speed internet/DSL Iphone Ipod/MP3 player Laptop computer Other Smart phone Satellite TV XM/Sirius Radio WI-FI None If you have a smart phone that is not in the list, please enter it here: Do you own/play any of the following games? (Select all that apply. Hold down the Ctrl key to make multiple selections) Gameboy Nintendo PC games on CD PC games online Sega Sony Xbox Trading Card Games Other None If you have a game system that is not in the list, please enter it here: Vehicles (Select all that apply. Hold down the Ctrl key to make multiple selections) Car Mini SUV Motorcycle/Scooter Truck SUV None Are any of your vehicles a hybrid? Yes No If yes: Select all that apply. Hold down the Ctrl key to make multiple selections) Car Mini SUV Truck SUV Political Affiliation Democrat Republican Independent Other