Embarrassing Personal Questions Form

NON-OPTIONAL NAME FIELD:

Name:

OPTIONAL TEXT FIELDS:

Address:
City:
State:
Zip+4:
Phone:
Fax:
Email:

Sexuality (select "one" from the following list):

Hetero
Mostly hetero
Bi
Mostly homo
Homo

Politics (select "any number" of choices from the list):

Democratic
Republican
Libertarian
Communist
Socialist Workers
Independent

Star Trek (select "one " of the choices):

Select from:

OR

Select from:

Comments (like I care):

Comments:

Erase all this (wipes out all your careful work if pressed):

NON-OPTIONAL SUBMIT BUTTON (send me the info):

Page created:	03/19/2005
Last modified:	02/09/2011
Author:	BPL