First Name: Last Name: Street Address:
City: State: Zip:
Email Address: Phone: Cell Phone:

Marital Status:

 Number of kids:  
expecting yes No Due Date
Occupation: Work Gender:
Full time Part time
Contractor Retired
Male Female

What Level of Education have
you completed

 What is your preferred method of shopping?
 
How would you describe your build?
 When shopping for apparel, do you look for any
of the following specialty sizes?
How many credit
cards do you have		 How many vehicles do you have?

Are you interested in
receiving credit card offers?
Yes No
How would you rate your credit:
# 1 Make Model Year
# 2 Make Model Year
# 3 Make Model Year
# 4 Make Model Year
How actively are you planning your retirement

Please indicate which credit cards you own:
Bank Debit Cards
Retail Store Cards
MasterCard
Visa 
American Express
Diners Club
Do you have any Student Loans Currently?
Yes No
How many student loans do you have?
If yes, then what is your estimated loan balance?
Are you eligible for deferment while you continue your education?
How often do you read for pleasure?
Are you a social drinker? If yes, what type of drinks do you prefer?
How proficient are you with a computer?
 

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only targeted offers that will save you time in your busy schedule.

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