Name:
Telephone:
E-mail:
Country	United States Australia Canada New Zealand Puerto Rico
Best time	Morning Afternoon Evening (for us to contact you)
Time Zone	Eastern Central Mountain Pacific Atlantic Hawaian Other

Please answer the following questions.

1.  Are You Interested In Making An Extra Income From Home?
	Yes No
2.  My main interest is:
	Business Opportunity Product Information Only
3.  If I am interested, I am willing to work:
	None 5-10 hours per week 10-20 hours per week Full time
4.  Available capital to start my own home based business:
	Select One $500-$1000 $1,000-$2,000 $2,000-$5,000 $5,000-$10,000 $10,000+
On a scale of 1 to 10 please rate the following: ("1" = little or no interest     /     "10" = strong interest)
5.  How serious are you about becoming wealthy?
	1 2 3 4 5 6 7 8 9 10
6.  How anxious are you to begin immediately?
	1 2 3 4 5 6 7 8 9 10
7.  How interested are you in earning commissions by sharing this program with others?
	1 2 3 4 5 6 7 8 9 10
8.  What is Your Occupation:
	Entrepreneur Computers/Internet Investor Corporate America Retired Medical Engineer Attorney Customer Service Stay-At-Home Mom Student Teacher Financial Retail Sales Retail Business Owner Marketing Independent Contractor Truck Driver Travel Agent Athletic/Sports Pastor Other