1. First Name :
2. Surname :     Title:
3. House No. & Street:
Suburb:
New Postcode :
Venue Area Preferred:

...

4. Telephone - Home :  
Telephone - Work :  
Telephone - Mobile :      Plan:
Mobile Plan with:
5. Email Address :
* We may email you from time to time regarding sessions, enter  
'OPT OUT' in the Email Address if you do not wish this to happen.
Email Check Frequency:  
6. Your Gender :  
Marital Status :
Ethnicity :
Date of Birth : Day(01-31)  Month(01-12) Year(1900-)
7. Job Title :

  (10 characters max.)

Employed Status :
Self Employed :      No. of Employees:
Which best describes your occupation :
8. Do you drink ? (set all that apply) :

Beer   Wine   Spirits  NON-Drinker

  Do you smoke :

...

9. Credit cards, (choose whichever apply) :      
10. What bank do you have your main account with :  
Have a Building Society account :      (10 characters max.)
Bank account(s) Savings    Cheque   Investment

...

11. These questions relate to your main car(s):
Car Make  :      
Car Model :      
Year of Manufacturer :      
Car insured with :     (10 characters max.)
Is this a company car :

...

12. How many pet : Cat    Dog
13. Do you have any children living at home, if so what is their year of birth :    Child BOY, year of birth (YYYY):
   Child BOY, year of birth (YYYY):
   Child BOY, year of birth (YYYY):
   Child GIRL, year of birth (YYYY):
   Child GIRL, year of birth (YYYY):
   Child GIRL, year of birth (YYYY):

...

14. Into which of the categories listed does the income of the entire household belong? (* categories)

Under $10,000 per year    
10,000 -$19,999 per year  
20,000 - $29,999 per year
30,000 - $49,999 per year
50,000 - $69,999 per year
70,000 - $89,999 per year
90,000   or more per year  

15. Do you own a Personal Computer :

Do you travel on business :

Do you have Pay TV :
Hear about us :

Comments :

Thank you 


 


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