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Asian        Pacific Islander           Native American

Other (Please Specify)

Country of Birth:

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Marital Status: Education:
Religious Preference: Employment:

Occupation:

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Student:    Major Course of Study:

Bank: (please check all that apply)

Bank of America     Citibank      Washington Mutual       Wells Fargo

Other (Please Specify)

Air Travel:

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Average Number of Pleasure Trips by Air Per Year:

Do you drink...   (Please select all that apply)

Beer Yes No
Wine Yes No
Mixed Drinks Yes No

Do you smoke?                  Are you registered to vote?

Registered Political Affiliation:

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Other Phone Numbers Where We Can Reach You:

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A Work Phone Yes No  If yes, please specify number Ext:
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