E-Mail Address

First Name

Last Name

Password

Confirm Password

Gender * Male Female

Date of Birth * (dd-mm-yyyy)

Mobile Number (not landline) *

Delivery Address (for courier delivery) *

Work Environment Small Office (1 - 30) Large Office (30+) Work Site (i.e. building sites) Workshop (i.e. fixed location) Vehicle / Travel based I am studying I don’t currently work (Retired/Mat leave etc)

Business Name, if delivering to work (including what Level)

Household Income Bracket * 0-$49,999 $50,000-$99,999 $100,000-$149,999 $150,000-$199,999 $200,000+

Ethnicity

Relationship Status * Single Partner - same household Partner - separate households

Phone - select all that apply

Mobile Phone Provider Telstra Optus Vodafone Virgin Mobile Other

Mobile Phone Account type Pre Pay Contract On Plan - no contract

Broadband - select all that apply

Broadband Provider Telstra Optus Vodafone Dodo iinet iPRIMUS Other

Energy Types - select all that apply

Energy Provider AGL Origin Energy Energy Australia Simply Energy ActewAGL Powershop People Energy Click Online Power and Gas Sum - Power Allinta Energy Red Energy Globird Dod - Power & Gas Momentum Energy Power Direct Other

Home Ownership - select all that apply

Retailers you shopped with (past 3 months)

Diet/Preferences - select all that apply

Interests/Lifestyle - select all that apply

Cinemas

Entertainer - select all that apply

Home Appliance - select all that apply

Skin Type

Hair Care - select all that apply

Personal/Health - select all that apply

Types of Insurance - select all that apply

Facebook name

Loyalty Programs – select all that apply

Google+ name

Instagram name