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Application For Secret Shopper Prefix First Name Middle Name Last Name Suffix Mr. Mrs. Miss. Ms. Dr. NONE Jr. Sr. II III IV SSN Date of Birth Race January Feburary March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Caucasian African American American Indian Asian Indian Hispanic Other Other: Gender Level of Education Male Female No High School Diploma High School Diploma Some College College Degree Current Employer Employer Contact Information Phone: Fax: Can contact employer: Contact Information Work Phone Cell Phone Fax Phone Pager Phone Home Phone Best Time To Call Address Information Address City State Zip Select A State Alaska Alabama Arkansas American Samoa Arizona California Colorado Connecticut District Of Columbia Delaware Florida Federated States Of Micronesia Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Marshall Islands Michigan Minnesota Missouri Northern Mariana Islands Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Palau Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming Own A Computer and On Internet Email Address Own A Car Maximum Distance Willing to Drive Miles Can only work during the day Can only work during the evening Can only work weekends Frequency willing to work 1 Time a Month 2 Times a Month 1 Time A Week 3 Times A Week 5 Times A Week Not willing to work at the following types of establishments: Skills Convicted of a crime Currently work for another shopping service Name of other shopping service I agree to keep client information confidential Been refused to become bonded Writing Skill Level Poor Fair Average Good Excellent How did you find us? Write a short description of your last dining experience Once completed with the form you can it to Count on Us.