Name:

Email:

Age:

City:

State:

Social Security Number:

What is your annual income?

What percentage of your annual income do you spend on drugs?

How often do you have sex a week?

With whom do you have sex?
NOTE: Please provide full names and phone numbers, if possible.

What are your prefered sexual positions (check all that apply):

Regular

Hump

On-top

What is your mom's name?

Where does your mom live?

Does your mom's home have a central security system?

Yes No

Do you have any of the following medical conditions:

Diarhea
Bad breath
Loose balls
Club feet
Bald
Lost limbs
Mental illness
Just plain dumb

Would you like to make a tax-deductible donation to the Larry Armstrong Home for Wayward Boys and Girls Fund (a unprofitable organization that helps people)?

Yes No

May we use all the information you have entered above, plus any information we can extract from your computer through any means available to us and Microsoft Corp., to sell to our clients, customers, friends, associates, third-parties, third-world countries, and anyone else who will buy it from us?

Yes No

Your comments:
Note: We really don't care what nonsense you have to say and probably won't respond, unless we want to screw with you.