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Shopper Questionnaire

Personal Details
Title

First Name:  
Surname:

Date of Birth / /
Gender:
Marital Status:
Address
HOME/SHIPPING ADDRESS:
Sub-building or Flat Number:    
House Number:
House or Building Name:
Street Name:
Post Town:
County:
Postcode:
Country:
How Can We Reach YOU?
Telephone Number (Day):
Telephone Number (Evening):
Mobil Phone Number:
Do You have access to a FAX MACHINE that you can utilize without charge?      
FAX Number:
Do you have a home computer?     
Do you have access to On-line computer Services?   
E-mail Address:
Confirm Email Address:
Alternate E-mail Address:
   
Who is your Internet Service Provider (ISP)?:
If Other, please specify:
How do you Connect to the Internet?:
HOW DID YOU HEAR ABOUT CINECHECK?
IF from a Search Engine, which particular one? ( AOL, Excite, Infoseek, Yahoo, ect.)
 
IF Other,
LIST NEIGHBORING POST TOWNS WHERE YOU WOULD ACCEPT ASSIGNMENTS:

1.

2.

3.

4.

5.

6.

 

 

 

Westgate, London W5 1UA