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