Last name

First name

Street address 1

Street address 2

City

State

Zip code

Telephone number

- -

E-mail address

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Mom's Birthday (MM/DD/YYYY)

Number of children

What is your total household income?

$20,000 - 35,000
$35,000 - 50,000
$50,000 - 70,000
$70,000 - 100,000
Over $100,000

How often do you purchase groceries?

Three times a week
Twice a week
Once a week
Once every other week

How much do you spend per shopping trip on average?

$25 - 50
$50 - 75
$75 - 100
Over $100

How often do you use coupons or other special offers when you shop?

Always
75% of the time
50% of the time
25% of the time
Never

If you sample a new product or receive a special offer or coupon, will you be more likely to try the product?

Yes
No

Yes, I am interested in receiving other offers and information about products for me and my family.