Survey Registration Form

Email Address:

Qualification Questions:

Date of Birth: (mm/dd/yy)

Sex: Male Female



Geographic location:

Please describe your industry:

What type of Computer do you use?

How do you get to the internet?

How many people are in your household ?

What is your marital status?

How many hours a week are you on the internet?

Have you ever purchased a product over the computer ? Yes No

If selected as a prize winner may we use your name ? Yes No

How did you hear about Voice of the Internet?