First name:????????
Last name:?????????
Home Phone:????
E-mail address:??
Number of family members:??
How did you hear about us:?
How much is your average weekly grocery bill:??
How many times a week does your family eat meats:??
We own a freezer:??
Yes
No
Do you own or rent your home:??
Own
Rent
Do you or your spouse work full-time:??
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Street Address:???
City or Town:??
Cell Phone:??
Best time to contact you:??
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