I have read the policies of Market Viewpoint, Inc., and I understand and will comply with these policies.*
Contact Information:
First Name	*
Last Name	*
Street Address	*
Street Address (line two)
City	*
State / Providence	Select One AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY AB - Alberta BC - British Columbia MB - Manitoba NB - New Brunswick NL - Newfoundland and Labrador NS - Nova Scotia NT - Northwest Territories NU - Nunavut ON - Ontario PE - Prince Edward Island QC - Quebec SK - Saskatchewan YT - Yukon *
Zip / Postal Code	* (US 5 digit, Canada 6 digit)
Work Phone
Home Phone	*
FAX
Contact E-mail	*
Do you have or be willing to use a Pay Pal Account?	Yes No *
Pay Pal Email Address?
Occupation:
Date of Birth:	Select One 1985-1990 1980-1984 1975-1979 1970-1974 1965-1969 1960-1964 1955-1959 1950-1954 pre 1950
Race / Ethnicity:	Select One American Indian / Alaska Native Asian Indian Asian other Black / African American Chinese Filipino Guamanian / Chamorro Hawaiian Native Japanese Korean Other Samoan Spansish / Hispanic / Latino Vietnamese White
Gender:	Male Female
Marital Status:	Select One Single Married Widow Divorced
Children?	Yes No
Ages:
Pets?	Yes No
Hobbies / Interests:
Availability:	Mon  Tue  Wed  Thu  Fri  Sat   Sun
Have you been convicted of a crime?	Yes No
If yes, describe:
Would you be willing to sign a release to obtain your credit history?	Yes No
Education:
High School Graduation Year
Some College	Yes No
How many years?
College Graduate?	Yes No
What College?
Year Graduated?
Annual Household Income?	Choose one Less than $18,000 $18 - $24,999 $25 - $34,999 $35 - $54,999 $55 - $74,999 $75 - $99,999 $100,000+
Shopping Experience:
List stores, malls, and restaurants that you frequent:
Do you prefer to shop at	malls   standalone stores
Do you shop at outlet malls?	Yes No
Have you ever Mystery Shopped?	Yes No
For what company?
What are your favorite television shows?
What type of music do you listen to?
Do you own a computer?	Yes No
What magazines do you read?
What newspapers do you read?
List clubs and organizations where you are a member:
References:
Provide 3 names and phone numbers:

Please click the "submit" button one time to submit to our office

Market Viewpoint
995 Fairview Road
Suite 202
Glenmoore, PA 19343-1813