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E-Mail programs

Others

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Now, some general information.

All information is required unless otherwise noted

First Name:
Last Name:
Address:
Address 2:
(Optional)
City:
State:
Zip/postal code:
Country:
Gender: male female
Education: highschool somecollege collegedegree masters phd
Employment:
Emplyment status:
Household Income: <$10,000 $10,000-$25,000 $25,000-$50,000 $50,000-$75,000 $75,000+
Number of People in Household: 1 2 3 4 5 6 7 8 9 10 more than 10
Phone number: ( ) (Please include area code)
Best time to call (Please include time zone, ie EST)
Social Security Number: - - (needed for tax forms)
Age:
Birthday: jan feb mar apr may jun jul aug sep oct nov dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 19
Marital status: single married

Some information about your online use

Hours spent online per month: <10 10-20 20-30 30-40 40-50 50+
How often do you buy online: every week every month every 1-3 every 3-6 every 6-12 every year never

What of the following have you purchased online in the last 6 months

Books
Financial Services
Software
Hardware
Flowers
Auctions

Please list your interests. Check all that apply. You must check at least 5. The more you check, the more paid advertisements you will recieve.

Now for your login information

Try to make your login easy to remember, but not so common that it will be taken. For example, both "chris" and "43kd98ke93" are bad login names, but "goober98" and "momasboy16" are good. You must use both letters (a-z) and numbers (1-10) in your username, and it should be between 5-10 characters long.

Same with your password. It should be easy to remember (but doesn't need to be so unique) and have both letters and numbers.

Some of these services will asign you a login name and/or password. some will let you choose your own, but will asign you a different Reference ID number. These will all be sent to you either by them or by me.

Login/user name:
Secondary login: (in case promary is taken)
Password:
Confirm password:

E-mail address:
Secondary E-mail: (For pay mail, optional)

The following are to retrieve your username/password if they are lost.

Mothers maiden name:
First love:
Optional question:
Answer:

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