Name:

Address:

City:

State: Zip:

Name:

Title/Position:

Address:

City:

State: Zip:

Email:

Personal Income: Select $0 - $50,000 $51,000 - $100,000 $101,000 - $125,000 $126,000 - $150,000 $151,000 - and up

Household Income Select $0 - $50,000 $51,000 - $75,000 $76,000 - $100,000 $101, 000 - $125,000 $126,000 - $150,000 $151,000 - $175,000 $176,000 - $200,000 $201,000 - $250,000 $251,000 - $300,000 $301,000 and up

Type of Business Select Sales Manufacturing Services Other

Number of Employees Select 10 - 50 51 - 100 101 - 500 501 - 1000 1,001 - 10,000 10,000 and up

Annual Revenue Select $100,000 - $500,000 $500,000 - $1,000,000 $1,000,000 - $1,500,000 $1,500,000 - $5,000,000 $5,000,000 and up

Involvement With The Internet: Select Currently Have Personal Access Currently Have Business Access Intent To Gain Access Soon for Personal Intent To Gain Access Soon for Business

Decision Maker Regarding Business Use Of: Select Internet LAN Telcom Interoffice Communications Other Communications Systems

Corporate World Wide Web Presence Select Business Web Site Personal Web Site Planning for a Business Site soon!