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Name:
Email:
Comment:
Email Address
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First Name
Last Name
PHONE NUMBER
DOB
SUBURB
Household situation
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Please select:
17yrs old or younger
Aged 18-45, no kids at home
Have young kids at home (under 10)
Have older kids at home aged (10-18)
Have kids both young and older kids at home
Over 45, all adults at home
Profession
CAR MAKE, MODEL AND YEAR
Household income
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less than $50 000
$50 000-$74 999
$75 000- $149 000
$150 000 plus
Number of years living in Australia
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Less than 5
5 or more
All my life
Where did you hear about us (or from whom)?
Work situation
Unemployed
Student
Part-time/Casual
Full-time
Retired
Stay at home parent
Business Owner
Gender
Female
Male