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CyberCoupons Card #

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First Name

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Your Birthday

Year: 19

Spouse First Name
(If applicable)

Spouse Last Name
(If applicable)

Spouse Birthday
(If applicable)

Year: 19

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Year:

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Cell Phone #
(Special offers by text message from CyberCoupons)

WHAT INTERESTS YOU?

Choose five or more of the options below that you are most interested in to help us motivate new advertisers you would like to see in our program.

Fast Food	Services for the Home
Dining	Medical / Dental / Hearing
Infant Needs	Professional Services
Day Care	Children's Interests
Hair Care	Beauty / Cosmetics
Pet Care	Consumer Services
Entertainment	Automotive Services
Apparel	Autos - New / Used
Home Improvement	Sports / Health / Fitness
Recreation	Grocery Coupons
Online Shopping	Travel / Leisure
Retail Shopping	Attractions
Christian Resources

I don't mind an occasional E-Mail if I get to see new offers.
Agree Somewhat Agree Somewhat Disagree Disagree

I like to use my discount to take others out to eat.
Agree Somewhat Agree Somewhat Disagree Disagree

I find the CyberCoupons Site to be well laid out and useful to me.
Agree Somewhat Agree Somewhat Disagree Disagree

I am usually the first in my group of friends to try something new.
Agree Somewhat Agree Somewhat Disagree Disagree

We want your suggestions:
Please feel free to write-in the names of your favorite restaurants and businesses you would like to see on our program.