Sample Form DEMOGRAPHIC INFORMATION 1. Of what state are you a permanent resident Outside USA Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Illinois Indiana Iowa Kansas Kentucky Louisianna Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Wisconsin Wyoming Choose a State 2. What County? 3. What is your zip code? 4. Please Check One:1. Male Female 5 What Is your Current Marital Status?: 1. Single 2. Married 3. Separated/ Divorced 4. Widow(er) 5. Refused 6. How many children 18 years or younger do you have? 1 2 3 4 5 6 7 8 9 10 7. In what year were you born? 8. What was the highest grade or year of school you completed? Graduate or Professional School Completed College Some College Business or Technical School Completed High School 9-11 years Eight years of less 9. What is your race? 1. Caucasian 2. African American 3. Asian 4. Other (specify) 5. Don't Know 6. Refused 10.Are you of Hispanic origin? 1. Cuban 2. Puerto Rican 3. Mexican 4. Other 5. Don't Know 6. Refused 11.Considering all sources of income for everyone living in your household in 1998 before taxes, what is your Household's income level? 1. less than $5,000 2. between $5,000 and $10,000 3. between $10,000 and $15,000 4. between $15,000 and $20,000 5. between $20,000 and $25,000 6. between $25,000 and $30,000 7. between $30,000 and $40,000 8. between $40,000 and $50,000 9. between $50,000 and $60,000 10. between $60,000 and $70,000 11. between $70,000 and $80,000 12. between $80,000 and $90,000 13. between $90,000 and $100,000 14. more than $100,000 15. Prefer Not to Say 12. Do you consider yourself an environmental activist a strong environmentalist a somewhat strong environmentalist a not particularly strong environmentalist not an environmentalist at all OPTIONAL PERSONAL INFORMATION Name: Organization: Address: City: State: Zip: Country E-Mail Address: Phone:
Sample Form
DEMOGRAPHIC INFORMATION
1. Of what state are you a permanent resident
Outside USA Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Illinois Indiana Iowa Kansas Kentucky Louisianna Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Wisconsin Wyoming Choose a State
2. What County?
3. What is your zip code?
4. Please Check One:1. Male Female
5 What Is your Current Marital Status?:
6. How many children 18 years or younger do you have? 1 2 3 4 5 6 7 8 9 10
7. In what year were you born?
8. What was the highest grade or year of school you completed? Graduate or Professional School Completed College Some College Business or Technical School Completed High School 9-11 years Eight years of less
9. What is your race?
10.Are you of Hispanic origin?
6. Refused
11.Considering all sources of income for everyone living in your household in 1998 before taxes, what is your Household's income level?
12. Do you consider yourself
an environmental activist a strong environmentalist a somewhat strong environmentalist a not particularly strong environmentalist not an environmentalist at all
OPTIONAL PERSONAL INFORMATION
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