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Name and address
First name
*
Last name
*
Suburb
*
Postcode
*
Contact details
Phone (H)
*
Phone (W)
Phone(Mobile)
E-mail address
*
Personal details
Gender
Male
Female
Date of birth
*
Marital status
- Select marital status-
Married
Single
De Facto
Separated
Widowed
Divorced
Residence
- Select residence -
Own home
Renting
Live with parents
Miscellaneous
Number of children
0
1
2
3
4
5
Do you have Pay TV?
No
Yes
Mobile phone provider
- Select mobile provider -
Telstra
Optus
Vodafone
Virgin
Other
Do you smoke ?
No
Yes
Do you drink alcohol ?
No
Yes