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| Last Name: |
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| Address Street 1: |
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| Address Street 2: |
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| City: |
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| Zip Code: |
(5 digits) |
| State: |
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| Daytime Phone: |
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| Evening Phone: |
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| Email: |
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About You:
What County do you work in? |
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| Your age: Under 20, 20-30, 40-50, 50-60, 60+: |
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| If you ride the Metro North to work each day please note? |
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| Do you drive to work each day? |
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| Do you have children living at home under 18 years of age? |
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| Do you have a pet? |
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ABOUT YOUR HOME:
Own a home, Rent a House, Apartment, Condo, or a Co-Op?
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| In the next six months do you intend to do any of the following? Fix or remodel your home? |
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| Interior Decorate your Home? |
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| Sell a Home? |
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| Buy a new Home? |
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| Move? |
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| IN THE NEXT SIX MONTHS: What will you need in the next 6 months: Go to the Car Wash? |
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| Visit a Doctor or Dentist? |
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| Buy a New Car? |
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| Visit a Holistic Store or Have Holistic Treatments? |
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| Go on Vacation? |
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| Go to the Gym? |
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| Purchase a Sports item? |
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| Go to a Day Spa? |
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| Further your (or a child’s) Education? |
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| Purchase Garden Equipment? |
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| Buy Flowers for an Event or a Holiday? |
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| Do you go out to a Restaurant at least once a month? |
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| Your Favorite Type of Restaurant is? |
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| Visit a Mens Store to buy Clothing for yourself? |
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| Visit a Womens Store to buy Clothing for yourself? |
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