First Name: Last Name: Street Address:
City: State:

Zip:
Email Address: Age Income Gender
male female
Presence of children Presence of credit cards Ethnicity Religious preference:
yes no yes no
How often do you attend services:
once a week twice a month once a month on religious holidays never
Religious travel:
never once a year twice a year three or more times per year
Religious publication subscribership:
None 1 publication 2 or more publications
Type of religious publications read:
Books Magazines Newsletters
Religious products purchasing:
None Holidays only Other than holidays
Do you make donations?
Yes No
If yes, what types of charities do you donate to? (please check all that apply)
Religious Health Related Causes Environmental Issues Political Animal Welfare Other

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