*use the next /back buttons to navigate pages. Click the send button on the page that completes your information

Number of people living in household
Person's last name?
Person's first name?
What is this person's phone number?
What is this person's email address?
Person's sex is?	male female
Person's age?
Person's date of birth?	mth: (mm)     day: year: (yyyy)
What is person's race?
Person's ethnic origin? e.g. Trinidad, Guyana...
Person is black?   (Afro- Caribbean)
Person is white ?
Person is indian?     (Indo - Caribbean)
Person is Chinese?
Person is Indigenous?
Mixed heritage (Choose all applicable boxes)
Person  is black?  (Afro-Caribbean)
Person is white ?	specify:
Person is  indian?  (Indo Caribbean)
Person is Chinese?
Person is  other?  (Portugese, Syrian, Lebanese.. etc)	specify:
Marital status	married widowed divorced separated
Person never married?
Person current  grade or level- attending?	nursery/preschool kindergarden grade1-4 grade 5-8 grade 9-12 college-undergrauate graduate or professional school
Person's - Highest degree or highest level of school COMPLETED?	No schooling nursery school or 4th grade 5th or 6th grade 7 or 8th grade 9 to 11 grade 12th grade less than 1 year college 1 or more years o college BS,AB,BA MA,MS,Meng,MEd,MSW,MBA MD,DDS,DVM,LLB,JD Phd,EdD
Person born in the US -  What state?	Select a state if applicable ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA GUAM HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING
Person born outside of the US - What country?	*select a country if applicable Antigua and Barbuda Antilles Netherlands Aruba Bahamas Barbados Cayman Islands Cuba Dominica Dominican Republic Grenada Guadaloupe Guyana Haiti Jamaica Martinique Montserrat Netherlands Antilles Puerto Rico Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Trinidad and Tobago Turks and Caicos Virgin Islands
Person is a US citizen?	Born in United States born abroad of american parents US citizen by naturalization Not a US citizen
Person came to the US in what year?	(yyyy)
Person served in armed forces, Reserves or National Guard?	active duty not now never from: to:
Person employment status
Person employment status?	Company employed self employed not employed
Type of work?	*select type of work if applicable Marketing. sales, PR & advertising Commercial, industrial & public sector Scientific research Engineering Health professionals Teaching professionals Information technology Nursing & health associate Business & financial associate Media, literary, design & sports Numerical clerks & cashiers Other clerical & secretarial Retail assistants Health & childcare related Armed forces & Agriculture Construction public protection service catering, waiting & bar staff
Yearly Income?	$
Person occupied address  is one of the following:	has a mortgage or loan owned free and clean rented for cash occupied without payment
Person's residence is one of the following types:	family house one family house apartment bld. other enter approiate field occupied when: built when: Rent ($) Mortgage($)
If person is property owner - value of property is:	*not applicable Less than $10,000 $10,000 to $14,999 $15,000 to $19,999 $20,000 to $24,999 $25,000 to $29,999 $30,000 to $34,999 $35,000 to $39,999 $40,000 to $49,999 $50,000 to $59,999 $60,000 to $69,999 $70,000 to $79,999 $80,000 to $89,999 $90,000 to $99,999 $100,000 to $124,999 $125,000 to $149,999 $150,000 to $174,999 $175,000 to $199,999 $200,000 to $249,999 $250,000 to $299,999 $300,000 to $399,999 $400,000 to $499,999 $500,000 to $749,999 $750,000 to $999,999 $1,000,000 or more