Name of Organization Requesting Information

Information Survey

The purpose of this survey is to collect information from you.

This survey is divided into the following sections:

Fill out the information in each section as requested. Then at the end of the form supply your name and contact information, and submit the form. You will receive a confirmation message from us shortly.

SECTION A -- General Information

In order to improve this site, please fill out this information as completly as possible

  1. How did you find out about this page?



  2. How many hours of television do you watch per week:

    None 1-5 hours 5-10 hours 10-20 hours More than 20 hours

  3. Giving us this information will sign you up for our mailing list, which will come out whenever get around to it.
    Name     
Street   
City     
State    
Zip Code 
    Country
    Main E-Mail Address
    Secondary E-Mail Address
    Home Phone Number
    Other Phone Number
    Language
    Home Page
    Age
    Gender
    Occupation: NATURE:
    Company: DIV/DEPT:
    		 NAME:
    		  
    Past Background: CATEGORY:
    		 FREE TEXT DESCRIPTION:
    Personal Interests: CATEGORY:
    		 DESCRIPTION - ENTER FREE TEXT OR...:
       
    Organization, Affiliation, Group: CATEGORY:
    		 DESCRIPTION - ENTER FREE TEXT:
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SECTION B -- Optional Information

This is stuff that you can fill out if you want. (All the cool people do!)

  1. How would you rate this Page?

    Bad Poor Fair Good Excellent

  2. What is your favorite color?



  3. Select the subject areas you are most interested in:

    History
    Geography
    Mathematics
    Economics
    Literature

  4. To Join Ryan's Elite Club, Type a username and password.

    Username
    Password
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SECTION C -- Title of this section

These are the instructions for filling out this section. These are the instructions for filling out this section. These are the instructions for filling out this section.

  1. Which of our products do you currently own? 
    SKU-01     SKU-04     SKU-07     SKU-10
SKU-02     SKU-05     SKU-08     SKU-11
SKU-03     SKU-06     SKU-09     SKU-12
  2. Please enter any additional comments regarding our products or services:



  3. Select a month from the following list, which shows 6 elements at a time:

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FORM SUBMISSION

Thank you for taking the time to answer the questions in our survey.

This explains how we plan to use the information you provide to us. We will also explain what benefits you receive from helping us in this way.

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Ryan McGuire
Copyright © 1995 ManCo. All rights reserved.
Revised: July 05, 1998.