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Name:      Last:         Middle:      First:

Nicknames/Aliases:

Screen Names:

Social Security Number: - -

Address:      Street:       City:      State:      Zip Code:

Phone Number: -

Home Page URL:

E-mail Address:      password:

ISP Provider:      connection:

Age:       Date of Birth:    Month:    Day:   Year:

Gender: Male     Female

Height: Feet    Inches          Weight: Lbs.

Hair Color:    Eye Color:    Identifying Marks (birth mark, scars, tattoos):

Marital Status:       Single       Married       Divorced

Sexual Orientation: Heterosexual     Homosexual     Bisexual

Names of Spouse/Significant Other(s)/ Children:

Race (check all that apply): White   African-Am   Asian-Am   Hispanic   Native-Am   Middle Eastern   Other

US Citizen: Yes No      Military: Yes     No      Religion:

Political Affiliation: Republican   Democrat   Independent  Communist   Marxist   Reform   Green

Gun Owner: Yes No          If Yes, do you have a license? Yes No     If yes, gun registration number

Occupation:    Title:     Employer:

Income: 100K +    75K+    50K+    25K+    10K+    Less than 10K    Unemployed

Name of Financial Institution:    Savings Balance:    Checking Balance:

Credit Card 1:   Card Number   Expiration Date:   Max Limit:

Credit Card 2:   Card Number   Expiration Date:   Max Limit:

Credit Card 3:   Card Number   Expiration Date:   Max Limit:

Car Owned:   Make:   Model:   Year:   VIN:

Health Record:     Diseases:         Mental Illness:

Allergic to Any Medications: Yes No     If yes what?

HIV Positive: Yes No          Have you ever had a STD? Yes No     If yes what?

Have you ever used illegal drugs?: Yes No     If yes, describe in detail

Have you ever been convicted of a felony?: Yes No     If yes, describe in detail

Please list major purchases that you will make in the next year      in the next five years

  Yes I would like to receive unimaginable volumes of unwelcome junk mail, spam e-mail, and telemarketing calls.

  Please sell my information to mailing lists, telemarketing lists, and customer profiling agencies.