Name Email Phone Gender

Address City Zip

Year in School Freshman Sophmore Junior Senior Major Most Nights I like to... Go Out Watch Television Listen to Music Talk on the Phone Study Entertain Friends Surf the Internet Other

Drinking Preference I Drink I Don't Drink I Occasionally Drink I Don't Like to be Around Drinking At All No Preference Smoking Preference I Smoke I Don't Smoke I Occasionally Smoke I Don't Like to be Around Smoking At All No Preference

Interest and Hobbies Comments

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