Please fill out the form below. Questions marked with an asterisk (*) are required.

Please tell us how you learned about Ingather Research by clicking on the appropriate response:

Friends/Family/Co-Workers Internet/Chat-Room/Bulletin Board Valpak Flyer Newspaper Ad TV Ad Radio Ad Database Event

If you selected Flyer, TV, Radio, Newspaper, or Database Event please type in the topic/name of ad/event:

Personal Information

First Name*:

Last Name*:

Home Phone*:

() -

Birth Date*:

--select month-- January February March April May June July August September October November December  Day: Year:

Email Address*:

Home Address*:

City*:

Arvada Aurora Beaver Creek Boulder Broomfield Centennial Central City Colorado Springs Commerce City Conifer Denver Edgewater Englewood Erie Evergreen Fort Collins Glendale Golden Greeley Greenwood Village Highlands Ranch Indian Hills Ken-Caryl Ranch Kittredge Lakewood Littleton Longmont Louisville Loveland Monument Morrison Northglenn Parker Thornton Westminster Wheat Ridge

State:

Colorado only

Zip Code*:

County:

-- Select -- Adams Alamosa Arapahoe Archuleta Baca Bent Boulder Broomfield Chaffee Cheyenne Clear Creek Conejos Costilla Crowley Custer Delta Denver Dolores Douglas Eagle El Paso Elbert Fremont Garfield Gilpin Grand Gunnison Hinsdale Huerfano Jackson Jefferson Kiowa Kit Carson La Plata Lake Larimer Las Animas Lincoln Logan Mesa Mineral Moffat Montezuma Montrose Morgan Otero Ouray Park Phillips Pitkin Prowers Pueblo Rio Blanco Rio Grande Routt Saguache San Juan San Miguel Sedgwick Summit Teller Washington Weld Yuma

Work Phone:

() -

Cell Phone:

() -

Fax:

() -

Gender:

 Female Male

Race:

--select-- African American American Indian, Eskimo Asian, Pacific Islander Caucasian Hispanic Other I do not want to say

Marital Status:

--select-- Divorced Married Single/Never Married Widowed Cohabitating Separated

Annual Household Income:

--select-- <25K 25-34K 35-44K 45-49K 50-74K 75-99K 100-149K 150-199k 200-249k 250k or higher

Employment Status:
(If retired, unemployed, or disabled, what was your previous occupation/industry?)

--select-- Full Time Part Time Retired Unemployed Disabled Student

Occupation/Industry:

Job Title:
(Check all that apply. Hold down the <ctrl> key while clicking to make multiple selections.)

Accountant/Bookkeeper Administrative Assistant/Office Manager Banker/Financial CEO/President/Owner Chef/Cook/Food Service Consultant Customer Service Rep. Data Entry/Processor Director Engineer Gov't Employee Health Care Human Resource Officer IT/Computer Hardware Software Tech Laborer Manager Military Real Estate Agent Sales Rep. Teacher/Professor/Educator Telecommunications Travel/Transportation Agent

Is this a home based business?

 Yes No

Are you self employed?

 Yes No

Education level:

--select-- Some High School High School Technical Some College College Graduate Post Graduate

Are you bilingual?

 Yes No

What Languages do you speak?
(Check all that apply. Hold down the <ctrl> key while clicking to make multiple selections.)

English Spanish French German Mandarin Other

Housing Type:

--select-- House Apartment Condominium Mobile home Other I do not want to say   Own Rent

Political party affiliation:

--select-- Democrat Republican Independent Other Not registered

Beverage Information

Do you Drink alcohol beverages?:

 Yes No

Type of alcohol beverages you drink:
(Check all that apply. Hold down the <ctrl> key while clicking to make multiple selections.)

Beer Bourbon Champagne Cordials Gin Rum Scotch Tequila Vodka Whiskey Wine Wine Cooler

Brands of beer typically consumed on a regular basis:
(Check all that apply. Hold down the <ctrl> key while clicking to make multiple selections.)

Amstel Amstel Light Anchor Steam Aspen Edge Avalanche Azteca Bass Beck's Blue Moon Bohemia Breckenridge Bud Light Budweiser Busch Busch Light Carta Blanca Coors Extra Gold Coors Light Coors Original/Regular Corona Corona Light Dos Equis Easy Street Fat Tire Foster Grolsch Guinness Hamms Hamms Light Heineken Honey Brown J.W. Dundee Keystone Keystone Light Killian's Labatt Blue Lowenbrau Light Lowenbrau Special Meister Brau Michelob Michelob Amber Bock Michelob Light Michelob Ultra Miller Miller Genuine Draft Miller Genuine Draft Light Miller High Life Miller High Life Light Miller Light Miller Reserve Light Milwaukee's Best Modelo Molson (any) Moosehead Natural Light Negra Modelo New Belgium (any) New Castle Old Milwaukee Old Milwaukee Light Old Style Pabst Blue Ribbon Pabst Blue Ribbon Light Pacifico Pete's Wicked Ale Pyramid Red Hook Rolling Rock Rolling Rock Light Sam Adams Saranac Schaefer Schaefer Light Schlitz Schlitz Light Sierra Nevada Sol St. Pauli Girl Tecate Tequiza Other

Average number of beers you consume per week:

1-6 7-12 13-24 25 or more

Type of beer you drink:
(Check all that apply. Hold down the <ctrl> key while clicking to make multiple selections.)

Domestic Import Light Microbrew Regular

Home Entertainment

Internet connection:

--select-- Cable DSL DSS ISDN Modem Wireless Other

Internet Provider:

--select-- @Home AOL AT&T Comcast Compuserve Earthlink ECentral Excite Gateway Juno KMart Mile High Online Mindspring MSN NetCom Netscape NetZero PCL Systems Prodigy Prolynx Qwest School USWest Worldnet Other

What is your level of computer competency?

I can turn it on Simple tasks/basic skills Internet Savvy Advanced Operations I taught Bill Gates

At home do you have:
(Check all that apply. Hold down the <ctrl> key while clicking to make multiple selections.)

Blackberry Bluetooth Cell Phone Computer-desktop Computer-notebook Digital Cable Digital Camcorders Digital Camera DirecTV DVD player DVR/Tivo Flat Screen TV GPS/Navigation HDTV Home Theater System Internet Internet-Cable Modem Internet-DSL Internet-High Speed Internet-Wireless iPod MP3 PDA Printer Satellite Satellite Radio Scanner

Radio stations you listen to:
– 1st Choice and 2nd Choice:
(Check all that apply. Hold down the <ctrl> key while clicking to make multiple selections.)

88.5-KGNU 89.3-KUVO 89.7-KWXA 90.1-KCFR 92.1-KJMN 92.5-KDJM 93.3-KTCL 94.7-KRKS 95.7-KISS 96.5-KXPK 97.3-KBCO 98.1-KKFM 98.5-KYGO 99.5-KQMT 100.3-KIMN 101.1-KOSI 102.5-KTRR 103.5-KRFX 104.3-KJCD 105.1-KOOL 105.5-KJAC 105.9-KALC 106.7-KBPI 107.5-KQKS 107.9-KBKL 560-ESPN 630-KHOW 710-KNUS 760-KTLK 850-KOA 910-KPOF 950-KKFN 990-KRKS 1190-KVCU 1280-KVOD 1430-KEZW 1510-KCUV 1600-KCKK 1690-KKDZ NPR NPS Other

TV stations you watch for news:
 – 1st Choice and 2nd Choice:
(Check all that apply. Hold down the <ctrl> key while clicking to make multiple selections.)

07 -ABC-KMGH 04 -CBS-KCNC 11 -CBS-KKTV CNN 13- FOX 31 -FOX-KDVR 21 -FOX-KXRM 50 -IND-KCEC 41 -IND-KRMT 53 -IND-KWHD 09 -NBC-KUSA 59 -PAX-KPXC 12 -PBS-KBDI 06 -PBS-KRMA 14 -Telefutura-KTFD 24 -Telemundo-KMAS 20 -UPN-KTVD 57 -UPN-KXTU 02 -WB-KWGN

What pets do you have?
(Check all that apply. Hold down the <ctrl> key while clicking to make multiple selections.)

Dog Cat None Other

Medical

Any health issues?
(Check all that apply. Hold down the <ctrl> key while clicking to make multiple selections.)

None Acid Reflux ADD/ADHD Allergies Alzheimer Arthritis Asthma Cancer COPD Dentures Diabetes Eczema Emphysema Epilepsy Erectile Dysfunction GERD HB pressure Hear Disease Hemophilia Herpes High Cholesterol HIV/AIDS Hypertension Hypothyroidism IBS Incontinent Kidney Disease Liver Condition Lupus Migraines Multiple Sclerosis Obesity Osteo Arthritis Osteoporosis Overactive Bladder Parkinson Seizures Skin condition Stress Stroke Thyroid Ulcer Weight West Nile Virus

Do you smoke?

--select-- No Yes

Your Primary Vehicle

Type:

--select-- Car Motorcycle RV SUV Truck Van

Make:

--select-- ACURA AUDI BENTLEY BMW BUICK CADILLAC CHEVY CHRYSLER DATSUN DODGE FORD GMC HONDA HYUNDAI INFINITI ISUZU JAGUAR JEEP KIA LANDROVER LEXUS LINCOLN MAZDA MERCEDES MERCURY MITSUBISHI NISSAN OLDSMOBILE PONTIAC PORSCHE ROLLS-ROYCE SAAB SATURN SUBARU SUZUKI TOYOTA VOLKSWAGEN VOLVO

Year:

--select-- 1985 or earlier 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Purchased:

--select-- New Used

Children

1st Child

Gender: Female Male

Birth Date:

Month: January February March April May June July August September October November December Day: Year:

2nd Child

Gender: Female Male

Birth Date:

Month: January February March April May June July August September October November December Day: Year:

3rd Child

Gender: Female Male

Birth Date:

Month: January February March April May June July August September October November December Day: Year:

4th Child

Gender: Female Male

Birth Date:

Month: January February March April May June July August September October November December Day: Year:

5th Child

Gender: Female Male

Birth Date:

Month: January February March April May June July August September October November December Day: Year:

6th Child

Gender: Female Male

Birth Date:

Month: January February March April May June July August September October November December Day: Year: