Market Decisions, Inc

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First and Last Name:

Gender:

City:

State:

Zip Code:

Phone Number:

Age Category:

Education:

Income:

Occupation/Title:

Own home or rent? Own Rent

Are you registered to vote in the state of Maine? Yes No

Marital Status:

Children - if so, age of children:

Do you have access to the Internet at your home? Yes No

If so, do you have high speed Internet access? Yes No