Golden Harvest Seed

Street
City
State	Alabama Alaska Alberta American Samoa Arizona Arkansas British Columbia California Canal Zone Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Trust Territories Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon

Never before	4
1	5
2	6 or more times
3

Friend or colleague/ word of mouth	Internet
Yellow pages	Billboard
Newspaper	Direct mail flyer
Television	Other (specify)
Radio

Excellent

Poor

Feature 1
Feature 2
Feature 3
Feature 4
Feature 5
Feature 6
Other (specify)

Feature 1
Feature 2
Feature 3
Feature 4
Feature 5
Feature 6
Other (specify)

Excellent

Poor

Much more expensive than I expected
More expensive
About what I expected
Less expensive
Much less expensive than I expected

Yes
No
Not sure

Very interested
Somewhat Interested
Not interested
Not sure

Yes
No, haven't tried it yet
No, didn't know about it

Yes
No
Not sure

What is your zip code?

Male
Female

Under 20 years	35 - 39	55 - 59
20 - 24	40 - 44	60 - 64
25 - 29	45 - 49	65+
30 - 34	50 - 54

Some high school or less	Associates degree
High school graduate	Bachelors degree
Attended some college	Post-college graduate

Yes, full-time
Yes, part-time (30 hours or less per week)
No

Married
Single, never married
Widowed
Separated or divorced

Under Age 6 years
Aged 6-12
Aged 13-18
Have no children 18 or under living in household

Under $10,000	$40,000 - $49,999	$80,000 - $89,999
$10,000 - $19,999	$50,000 - $59,999	$90,000 +
$20,000 - $29,999	$60,000 - $69,999
$30,000 - $39,999	$70,000 - $79,999

American Express	Diners Club
MasterCard	Department Store
Visa	Gasoline Co.
Discover/Novus	Do not use credit cards

First Name
Last Name
Address 1
Address 2
City
State	Alabama Alaska Alberta American Samoa Arizona Arkansas British Columbia California Canal Zone Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Trust Territories Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon
Zip / Postal Code
Home Phone
Work Phone
E-mail
Fax