1) First Name or Initial

2) Middle Initial    3) Last Name WHY

5) City 6) State    Zip   WHY

8) Country   WHY

9) email Address   WHY

10) Are you WHY
MaleFemale

 11) Do you WHY
Own  or Rent your residence?

 12) Please enter your Month & Year of  Birth: WHY
Month:  01 02 03 04 05 06 07 08 09 10 11 12    Year:    

13) What is your highest level of education completed? WHY

No degreeHigh SchoolSome CollegeAA or Trade Certificate
Undergraduate Degree Graduate Degree Doctorate

14) What is Your Annual Gross Household, (total estimate of everyone living in your home) Income? WHY
(US dollars, 000)

Less than $40K $40K-$50K $50K-$60K$60K-$75K
$75K-$90K $90K-$100K$100K-$150K $150K-$200K
$200K +

15) What is your marital status? WHY

Married Single (Never Married) Separated Divorced
Widow

15b) If married, in what year did you marry?  WHY

 15c) Is this your WHY

1^st Marriage2^nd Marriage 3^rd Marriage 4+

16) If not married, are you currently in a long-term relationship? WHY
(Skip 16-16c if married)

Long-term is more than 6-months together

16a) How Long Have You Been Together? WHY

months (1 year = 12 months)

16b) Do you live together?  WHY

Yes     No

16c) Are you engaged? WHY

Yes   No

17) Do you have children under 18 years of age?   WHY

Yes    No        Prefer not to answer

17a) If yes, what are their ages? WHY
Check all that apply

0-2 2-5 6-11   12-14 15-18     Prefer not to answer

17b) Is your family bi-nuclear? WHY
Are the children from more than one marriage/father with step children/children of the current marriage mixed together?

Yes       No

18) Do your children live with you? WHY
Yes No  Prefer not to answer

19) What is your race? (check all that apply) WHY

Caucasian African American    Asian/Pacific Islander
Hispanic Native American Middle Eastern
Indian/Malaysian Native African Southeast Asian          
Prefer Not to Answer

20) What is your religion? WHY

Catholic Protestant (includes all non-Catholic and non -Mormon Christian Faiths)
Mormon Jewish MuslimHindu Buddhist Atheist
New Age Other Prefer Not to Answer

Opt-in and Opt-out Preferences

Since Couples Company does not sell, grant access to or lease our member information, the only way a manufacturer or retailer can provide special incentives to you  is by offering a special discount or incentive through the club benefits program that you can be use on or offline, or by purchasing an ad or sponsorship within the site or e-zine. Couples Company, not the manufacturer or retailer will notify you of these offers if you choose yes in the following question.

21) Do you want Couples Company to inform you about the discounts and specials buys you are entitled to through your club membership as they become available?

Yes      No

Couples Company and our experts will on occasion tour the US and Canada or other countries.  At times we will hold events and parties in the destination city for our members.

22) Do you want Couples Company to inform you about special events, contests and other activities associated with your membership as they become available?

Yes      No

As membership grows, Couples Company will be adding first monthly and later weekly e-zines with tips to improve your relationship.

23) Do you want Couples Company to notify you of new newsletters or other products developed by Couples Company to help your relationship as they become available?

Yes      No

 21) Where do you connect to the Internet? WHY

 22) What are your favorite leisure time activities?
(Check all that apply) WHY

 23) If you could travel anywhere in the world, where would you like to go? WHY

24) If you could improve anything about yourself and your life, what would it be? WHY

 25) Finally….How did you learn about CouplesCompany.com? WHY

News Story Radio Commercial Talk Show Magazine Ad Magazine Article Newspaper Television Search Engine Partner Web Site Online Advertisement Friend/Spouse Other