Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Age Range * 18-24 years old 25-34 years old 35-44 years old 45-54 years old 55-64 years old 65-74 years old 75 years or older Ethnic Background * American Indian (Native American) Hispanic African American (Black) African (Somali) African (Oromo) Asian (Hmong) Asian (Other) Caucasian Tribal Affiliation * Veteran * Vietnam Era Veteran Veteran Non-Veteran Other Gender * Female Male Non-binary Education * Elementary High school graduate, diploma or the equivalent (GED) Some college credit, no degree Associate Degree/Trade/Technical/Vocational Training Bachelor’s degree or other 4 year degree Master’s Degree Professional Degree Doctorate Degree No Schooling Completed Income * Less than $25,000 $25,000 to $34,999 $25,000 to $34,999 $50,000 to $74,999 $75,000 to $99,999 $100,000 to $149,999 $150,000 or more Adults in Household * Children in Household * Are you currently in Business * Yes No Thank you!
