| First Name: |
Last Name: |
Address: |
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| City: |
State |
Zip: |
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| Email Address: |
Gender: |
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Male
Female |
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| Age: |
Income: |
Children: |
How many: |
Under age of 18: |
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Yes
No |
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| Multimedia: |
| Do you own a High Definition TV: |
Do you own a Plasma Screen TV: |
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| Do you have cable in your home: |
Do you have a satellite dish: |
Do you have a home theater package: |
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| Internet Connectivity:(check one) |
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Dial Up
DSL
High Speed
Cable
VoIP |
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| Other media: |
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Computer
iPod
mp3 player
Video games |
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| Future multimedia purchases: |
| Do you intend to purchase the following in the next 6-12 months: (check one) |
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HDTV
Cable
Plasma TV
Satellite dish package |
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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 |
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