1) First Name
Last Name
Email Address
2) Address 1
Address 2
City
State     Zip  
3) Area Code and Phone Number
(OPTIONAL)		     - 
4) Date of Birth
(mm/dd/yyyy)		  /   / 
5) What is your current marital status?
Single, meaning never married
Single, but living with a significant other
Married
Separated or divorced
Widowed
6) Are you ...?
Male
Female
7a) How many children are currently living in your household?
 0    1    2    3    4    5    more than 5  
7b) How many children are currently living outside your household?
 0    1    2    3    4    5    more than 5  
8) Children’s Date(s) of Birth (mm/yyyy)
(OPTIONAL)
Child 1  /      Child 2   /     Child 3   / 
Child 4  /      Child 5   /     Child 6   / 
 
9) Do you work outside of the home?
Full Time
Part Time
Don’t work outside the home
10) In what area are you employed?
Agricultural
Computers/Technology
Construction
Corporate
Health Care
Industrial/Production/Factory
Retail
Teaching
Other
11) Which of the following categories best describes the highest level of education you have completed? (SELECT ONE ONLY)
Some high school or less
High school graduate
Vocational or technical school, but no college
Some college, did not graduate
Graduated college
Post-graduate work or degree
12) What is your race or ethnic group?
(OPTIONAL)
White or Caucasian
Black or African-American
Hispanic or Latino
Asian or Pacific Islander
Alaskan Native or American Indian
Other
13) Which of the following areas are you interested in?
(SELECT ALL THAT APPLY)
Beauty Movies/DVDs
Crafts Music
Entertaining Pets
Exercise Reading
Fashion Relationships
Food/Cooking Travel
Gadgets/Electronics Volunteer/Charity Work
Health Weight loss
Home Decorating Work/Career
Home Repair I am not interested in any of the above
14) Which of the following categories best reflects how you personally buy or read ALL YOU?
I currently subscribe to ALL YOU
I buy ALL YOU regularly (at least 2 of the last 4 issues)
I buy ALL YOU occasionally (at least once in the past 6 months)
I read ALL YOU, but do not personally buy
I do not buy or read ALL YOU
15) How did you hear about the Reality Checkers?
Email Invitation
Ad in ALL YOU
From a Friend/Colleague
Other (please specify:)  
Don't Know
16) Are you interested in representing ALL YOU in your local press?
 YES    NO
17) How many times a month do you shop at Wal-Mart?
I never shop at Wal-Mart
I shop at Wal-Mart every few months or less often
1-2
3-4
5-6
7-8
9 or more
18) Which of the following reasons best describes why or how you shop at Wal-Mart?
(SELECT ONE ONLY)
I buy as much as I can at Wal-Mart.
I tend to purchase grocery, household and/or cleaning products more than clothing and/or home décor items at Wal-Mart.
I don’t consider myself a “Wal-Mart shopper” but I’m smart enough to know I can sometimes get great items there (brand-name or not), at great prices.
19) Which Wal-Mart departments do you shop in?
(SELECT ALL THAT APPLY)
Appliances Home
Baby Intimate apparel
Beauty (eg. cosmetics, skin care) Pet Food
Electronics Pharmacy
Grocery Photo
Hardware/Paint Women's apparel and shoes
Health Other
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