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Please fill out the following form honestly and accurately. All information will be kept private.

Note: Some information may seem unnecessary. Don't worry. This is just routine data we collect for our research.

Name: 
Payment by:
Visa Visa
Master Card Master Card
Check


Credit Card Numbers: 

E-mail: 

Address: 

City:    State:    Zip: 
 

What is your income?
Below $10,000
$10,000 to $20,000
$20,000 to $50,000
$50,000 to $100,000
$100,000 to $150,000
Over $150,000
 

When do you go on vacation?

Do you own an extra key to your house?

Where do you keep it?

 
 

Do you own the following...


Television?

Yes
No
 
VCR?
Yes
No
 
Stereo System?
Yes
No
 
Jewelry?
Yes
No
 
Coin Collection?
Yes
No

 
Do you have any of the following...


Security System?

Yes
No
 
Dog?
Yes
No
 
Neighborhood Watch?
Yes
          No
 
How would you rate the police service where you live?
Excellent
Good
Decent
Average
Mediocre
Poor
        
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