Please select all answers
Please choose an answer
When is your Birthday?
*
Select a date
1
2
3
4
5
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9
10
11
12
13
14
15
16
17
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19
20
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25
26
27
28
29
30
31
Select Month
January
Febuary
March
April
May
June
July
August
September
October
November
December
';
Select Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
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1991
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1981
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1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
Please choose an answer
What is your gender?
*
--Select--
Male
Female
Please choose an answer
What is your zipcode?
*
Please choose an answer
What is the highest level of education you have completed?
*
--Select--
3rd Grade or less
Middle School - Grades 4 - 8
Completed some high school
High school graduate
Other post high school vocational training
Completed some college but no degree
Associate Degree
College Degree (such as B.A,B.S.)
Completed some graduate
Masters degree
Doctorate degree
None of the above
Please choose an answer
Which of the following best describes your race?
*
--Select--
White
Black or African American
American Indian or Alaska Native
Asian
Asian Indian
Asian - Chinese
Asian - Filipino
Asian - Japanese
Asian - Korean
Asian - Vietnamese
Asian - Other
Middle Eastern
Pacific Islander
Pacific Islander - Native Hawaiian
Pacific Islander - Gaumanian
Pacific Islander - Samoan
Pacific Islander - Other Pacific Islander
Hispanic or Mixed/Some other race
Prefer not to answer
Please choose an answer
What is your current employment status?
*
--Select--
Employed full-time
Employed part-time
Self-employed full-time
Self-employed part-time
Active military
Inactive military/Veteran
Temporarily unemployed
Full-time homemaker
Retired
Student
Disabled
Prefer not to answer
None of the Above
Please choose an answer
How much total combined income do all members of your household earn before taxes? ( This includes money from jobs; net income from business, farm, or rent; pensions; dividends; interest; social security payments; and any other money income received by members of your household that are eighteen (18) years of age or older. )
*
--Select--
Less than $5,000
$5,000 to $9,999
$10,000 to $14,999
$15,000 to $19,999
$20,000 to $24,999
$25,000 to $29,999
$30,000 to $34,999
$35,000 to $39,999
$40,000 to $44,999
$45,000 to $49,999
$50,000 to $54,999
$55,000 to $59,999
$60,000 to $64,999
$65,000 to $69,999
$70,000 to $74,999
$75,000 to $79,999
$80,000 to $84,999
$85,000 to $89,999
$90,000 to $94,999
$95,000 to $99,999
$100,000 to $124,999
$125,000 to $149,999
$150,000 to $174,999
$175,000 to $199,999
$200,000 to $249,999
$250,000 and above
Prefer not to answer
Please choose an answer
Approximately what is the annual revenue for your organization?
*
--Select--
Under $100,000
$100,000 - $249,999
$250,000 - $499,999
$500,000 - $999,999
$1 Million - $4.99 Million
$5 Million - $9.99 Million
$10 Million - $24.99 Million
$25 Million - $49.99 Million
$50 Million - $99.99 Million
$100 Million - $249.99 Million
$250 Million - $499.99 Million
$500 Million - $999.99 Million
$1 Billion or more
I don't work/I don't know
Please choose an answer
What is your state?
*
--Select--
ALABAMA(AL)
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
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
American Samoa
Federated States of Micronesia
Guam
Marshall Islands
Northern Mariana Islands
Palau
Puerto Rico
Virgin Islands
Please choose an answer
What is your postal code?
*
--Select--
SampleCube_ZIP_UZ
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