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Additional information

Country*	- none of the listed -AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntiguaAntillesArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBarbudaBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCayman IslandsChadChile, Rep. ofChinaChristmas IslandColombiaComorosCook IslandsCosta RicaCroatiaCubaCyprusCzech Rep.DenmarkDiego GarciaDjiboutiDominicaDominican Rep.EcuadorEgyptEl SalvadorEritreaEstoniaEthiopiaFaeroe IslandsFalkland IslandsFijiFinlandFranceFrench AntillesFrench GuianaFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotte IslandMexicoMoldova, Rep. ofMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNevisNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarReunion IslandRomaniaRota IslandRussiaRwandaSaint LuciaSaipan IslandSan MarinoSaudi ArabiaScotlandSenegalSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSt. HelenaSt. KittsSudanSurinameSwazilandSwedenSwitzerlandSyrian Arab Rep.TaiwanTajikistanTanzaniaThailandTinian IslandTogoTokelauTongaTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited KingdomUruguayUSAUzbekistanVanuatuVatican CityVenezuelaViet NamWalesWestern SamoaYemenYugoslaviaZambiaZimbabwe
Occupation	- none of the listed -Aircraft pilot (private)Computer programming, information technology, etc.DentistEngineer or computer scientistFarming, ranching, forestry, or fishingInternet programming, web design, ISP, webmaster, etc.Military (Army, Marines, Air Force or other special corps)Nurse, nursing, or similar health caretakerPharmacistProfessor, instructor or teacher in college/universityStock broker, stock analyst, investment analystStudentOther occupation
Time set*	- none of the listed -(GMT -12:00) Eniwetok, Kwajalein(GMT -11:00) Midway Island, Samoa(GMT -10:00) Hawaii(GMT -9:00) Alaska(GMT -8:00) Pacific Time (US & Canada)(GMT -7:00) Mountain Time (US & Canada)(GMT -6:00) Central Time (US & Canada), Mexico City(GMT -5:00) Eastern Time (US & Canada), Bogota, Lima(GMT -4:00) Atlantic Time (Canada), Caracas, La Paz(GMT -3:30) Newfoundland(GMT -3:00) Brazil, Buenos Aires, Georgetown(GMT -2:00) Mid-Atlantic(GMT -1:00) Azores, Cape Verde Islands(GMT) Western Europe Time, London, Lisbon, Casablanca(GMT +1:00) Brussels, Copenhagen, Madrid, Paris(GMT +2:00) Kaliningrad, South Africa(GMT +3:00) Baghdad, Riyadh, Moscow, St. Petersburg(GMT +3:30) Tehran(GMT +4:00) Abu Dhabi, Muscat, Baku, Tbilisi(GMT +4:30) Kabul(GMT +5:00) Ekaterinburg, Islamabad, Karachi, Tashkent(GMT +5:30) Bombay, Calcutta, Madras, New Delhi(GMT +6:00) Almaty, Dhaka, Colombo(GMT +7:00) Bangkok, Hanoi, Jakarta(GMT +8:00) Beijing, Perth, Singapore, Hong Kong(GMT +9:00) Tokyo, Seoul, Osaka, Sapporo, Yakutsk(GMT +9:30) Adelaide, Darwin(GMT +10:00) Eastern Australia, Guam, Vladivostok(GMT +11:00) Magadan, Solomon Islands, New Caledonia(GMT +12:00) Auckland, Wellington, Fiji, Kamchatka

Location Information

State	- Please Choose -AlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
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Additional information

Do you want to be registered for our mom survey and sampling panel? *	Yes, of course! No, not right now. You'll receive opportunities to try out new products and services and asked your opinion about them.
Your Birth Year
Do you:	- Please Choose -Work Full-timeWork Part-timeAm at home with the kidsOtherNone of the above
If you work full or part-time, do you work:	- Please Choose -At homeOut of an officeBoth
Do you own your own business?	- Please Choose -YesNo
If so, how many employees?
Your Marital Status is:	- Please Choose -MarriedIn a partnered relationshipSingleDivorcedSeparatedWidowed
What is the highest level of education you have completed or the highest degree you have received?	- Please Choose -Currently a StudentDid not complete high schoolGraduated High SchoolJunior CollegeGraduated CollegeMaster/Doctoral/Other Advanced degree Professional Degree (MBA, JD, MD)
Do you consider yourself:	- Please ChooseWhite/CaucasianBlack/African American Asian/Pacific IslanderHispanic or LatinoNative American/Alaskan NativeOther
Your approximate Household Income	- Please Choose -<$25K$26K -50K$51K – 75K$76K- 100K$101K – 150K$151K+
Are you:	A Homeschooler Passionate about going green A Pet Owner Mom of Multiples A Teacher Empty Nester Caretaker of your parents Mom of Special Needs Kid(s) Small Business Owner Allergy Sensitive kids or family Passionate about Organic Homeowner
Are you a leader of any of the following? (Check all that apply)	Troop Leader Organized sports Team(s) School Volunteer PTO/PTA Organized Playgroup(s) Cultural & Arts Program(s) Teacher/Education Political Group(s) Religious Group(s) Homeroom Mom
Other Groups you may be a Leader of
Computer Type	- Please Choose -MacPCBoth
Sites You are Active On	MySpace Facebook Ning Gather Twitter LinkedIn Flickr
Other Sites
Stores you Shop at	Target Safeway Sam's Club Wal-Mart Stop & Shop BJ's Trader Joes Omni Foods Whole Foods Cosco
Are you a Mom who Blogs?	Yes, sign me up to be a part of blog tours!
If yes, please share your URL

Child Information

Number of Children	- Please Choose -123456+I'm expecting!No kids just yet.
Child #1 Birth Date Year
Child #2 Birth Date Year
Child #3 Birth Date Year
Child #4 Birth Date Year
Child #5 Birth Date Year
Child #6 Birth Date Year