| Please complete the following: |
| 1. First Name: |
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| 2. Last Name: |
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| 3. Phone: |
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| 4. E-mail: |
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| 5. Do you share your E-mail with another person:
Yes
No |
| 6. Address: |
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| 7. City: |
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| 8. State/Province: |
or Territory
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| 9. Zip/Postal Code: |
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| 10. Country: |
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| 11. Year of Birth: |
19
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| 12. Gender: |
Male
Female |
13. Please provide the month and year you started browsing the web:
Year |
| 14. Have you ever purchased products online:
Yes
No |
| 15. If "yes", in which of the following categories have you purchased products or services online: (choose all that apply) |
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| 16. Have you ever purchased products or services from a catalog :
Yes
No |
| 17. If “yes,” in which of the following categories have you purchased products or services from a catalog: (choose all that apply) |
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| 18. Do you currently subscribe to any magazines:
Yes
No |
| 19. If "yes", in which of the following types of magazines do you subscribe to: (choose all that apply) |
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| 20. Specifically, which magazines do you subscribe to? (Please list each magazine in a separate box.) |
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| 21. Have you purchased any magazines from a newsstand/store in the last year:
Yes
No |
22. If “yes,” how often do you usually purchase magazines from a newsstand/store?
Less than 3 times a year
3-6 times a year
7-11 times a year
Once a month
Every other week
Every week
Never purchase magazines from a newsstand/store
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| 23. Which of the following types of magazines do you purchase from a newsstand/store: (choose all that apply) |
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| 24. Specifically, which magazines do you usually purchase from a newsstand/store: (Please list each magazine in a separate box.) |
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25. How many children under 18 are currently living in your home:
None
1
2
3
4
5
More than 5
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26. What is your employment status:
Full-time
Part-time
Student
Retired
Other
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| 27. Which of the following areas best describes your occupation? |
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| 28. What is your job title:
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29. What is your current marital status:
Single
Living with significant other
Married
Separated
Divorced
Widowed
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30. What is your household income (before taxes):
Under $25,000
$25,000-$49,999
$50,000-$74,999
$75,000-$99,999
$100,000-$149,000
$150,000 or higher
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