First Name: Last Name: Street Address:
City: State Zip:
Home Phone Cell Email
Gender: Age: Marital Status: Spouse's Name
Male   Female
Married Single
Are you the head of household?
Yes No
Your Income
Household Income
Do you have children? If so, how many?
1 2 3 4 5
Yes No
  Age Name Birth Month and Year
First Child
Second Child
Third Child
Fourth Child
First Child
How many years of education do you have? How many years of education does your spouse have?
How do you identify your ethnicity?
African American Native American Asian American Caucasian Hispanic Other
Are you first or second generation?
1st 2nd does not apply
What is your primary language spoken?
Do you prefer to receive offers in your primary language?
Yes No
What country of origin or culture do you identify with?

African

Bulgarian

Ethiopian

Hungarian

Korean

Phillippino

Swiss

Albanian

Cambodian

Finnish

Icelandic

Laotian

Polish

Thai

Algerian

Chinese

French

Indian

Latvian

Portuguese

Turkish

Arabian

Czech

French

Indonesian

Lithuanian

Russian

Ukrainian

Armenian

Danish

German

Irish

MidEastern

Scandinavian

Vietnamese

Austrian

Dutch

Greek

Italian

Norwegian

Scottish

Welsh

Azerbaijani

Eastern European

Hindi

Japanese

Other Asian

South African

Yugoslavian

Bengladesh

English

Hindu

Jewish

Pakistani

Sri Lankan

Other
Bosnian/Herz Estonian Hispanic Kazakstani Persian Swedish
Do you own or rent? How many years at your current location? How do you like to shop?
Own Rent
Retail
Yes No
Catalog
Yes No
Online
Yes No
Please respond to the following statements:
 

STRONGLY AGREE

AGREE

NEUTRAL

SOMEWHAT DISAGREE

STRONGLY
DISAGREE

I love to shop online

I feel confident buying online

I prefer to use my credit card online

I don't trust buying online

I research prodcuts online before buying them in stores

I love to shop in catalogs

I can't wait for my favorite catalog to come in the mail

I prefer to call my catalog orders in to order

I prefer to go online when placing my catalog order

I always respond to sales

I love last minute deals

I love to shop in person

I love malls

I lover boutique shops

I love to go to large retail outlets

Thank you for your time. The information you provided will help us bring you only
targeted offers that will save you time in your busy schedule.

Unless I have checked any of the boxes below, Take 5 Solutions, LLC will assume that I do not mind receiving online, postal or SMS offers:
  
I would prefer not to receive online offers, product information,
specials, updates from third party advertisers
 
I would prefer not to receive postal offers, product information,
specials, updates from third party advertisers