To go any further you must register by filling out this form. Please answer each question completely and truthfully as this form will be verified. Not completing this form will severely limit the functionality of your computer's operating system. If you do not wish to submit this form you will be prompted to do so frequently. All information becomes property of SmallLimp corporation, it's partners and affiliates. No further use of your information may be used without the express written consent of SmallLimp. Please fill out this form and help us help you. Thank you.

Name:      Last:         Middle:      First:


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.