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We are conducting a paid market research study on the topic of Social Issues. If you are interested in participating, please respond with the information below.

Name:
Age:
Gender:
Phone:
City / County in which you live:
Ethnicity:
Occupation:

Top 3 favorite bars / restaurants:

Do you smoke cigarettes? If so, what brand?

What is your favorite brand of beer?

What liquor do you drink most often?

Do you have children? If so, what are their ages?