Name ________________________________________ Age _______

Address _________________________________________________

City _____________________________________________________

State ___________ Zip code _________________________________

Phone ___________________________________________________

E-mail ___________________________________________________

How far are you willing to commute? _____________ miles

What passions would you like to share with others?

_________________________________________________________

What interests do you desire to learn more about?

_________________________________________________________

When is the best time for you to participate in activities?

_________________________________________________________

When is the best time to call you? _____________ AM / PM

How did you here about iGroups?______________________________

What radio station do you listen to frequently? ___________________

What newspaper so you read weekly? __________________________

Add me to the e-newsletter list? Yes / No