First Name	Last Name
Address	Apt/Suite #	(optional)
City	State   AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY	Zip Code

The following is the information you will use to login to the website in the future. Choose a password which is easy to remember but difficult to guess. Note: your username cannot be changed.

Username	(Must contain only letters and numbers; from 3 to 25 characters long)
Password	(Must be between 6 and 50 characters long; case-sensitive)
Confirm password	(Both passwords must match)
Your Email Address
Referrer	(If you were referred by a friend, enter their username here)

We offer a variety of ways to get your reward. Choose the method that you prefer. You may change your payment method at any time.

Payment Method	PayPal Check If you would like to receive payment via Direct Deposit, just choose "Check" for now. You can set it up later.
Payment Email

Demographic Information

Birth Date	--- (01) Jan (02) Feb (03) Mar (04) Apr (05) May (06) Jun (07) Jul (08) Aug (09) Sep (10) Oct (11) Nov (12) Dec / --- 12 34 56 78 910 1112 1314 1516 1718 1920 2122 2324 2526 2728 2930 31 / (Format: mm/dd/yyyy)
Racial Background	-- SELECT -- African American, Black, Haitian American Indian, Native American, Alaskan Native Asian, Middle Eastern Native Hawaiian, Pacific Islander Caucasian, White Hispanic/Latin American Decline to state
I Identify With	» -- SELECT -- Asian Indian Chinese Filipino Japanese Korean Vietnamese Pacific Islander Middle Eastern Other Asian
Gender	MaleFemale

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