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Name*
TitleForenameSurname
Address Line 1*
Address Line 2*
Address Line 3
Address Line 4
Postcode*
Home Telephone Number*
(Including the STD code)
Mobile Phone Number
Work Telephone Number
(Including the STD code)
Email*
Gender* Male
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Date Of Birth*
(Eg. 10/07/1988)
DayMonthYear
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Are you in full-time education?* Yes
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Occupation*
Which of these statements best describes the current occupation of the chief income earner in your household (previous occupation if retired)?
Professional, senior management or top level civil servant.
Principle officer in local government or civil service.
Middle management in large organisation or top
     management/owner of small business, educational or service
     establishment.

Junior management or other non-manual work.
Skilled manual worker or manual worker with supervisory
     responsibilities.

Semi-skilled or unskilled manual worker, apprentice or trainee to
     skilled manual workers.

Casual worker or without regular income.
Dependent on state benefits (or state pension) only.
Do you have internet access at home?* Yes
No
Household Size*
(Number of people, including yourself, permanently resident in your home)
1
2
3
4
5+
Are you mainly responsible for the grocery shopping in your household?* Yes
No
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