| Gender: |
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| Age: |
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| Ethnicity: |
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Highest Grade Completed: |
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| Occupation: |
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| Children at Home: |
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| Household Income: |
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| Zip Code: |
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| SNACK USAGE |
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(Please fill in only the boxes that reflect your personal purchase and consumption.) |
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| Potato Chip Brand Bought Most Often: |
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If Other, please specify:
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| How many bags of each size do you buy a month? Please input the number in the appropriate box. |
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| Pretzel Brand Bought Most Often: |
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If Other, please specify:
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| How many bags of each size do you buy a month? Please input the number in the appropriate box. |
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| Tortilla Chip Brand Bought Most Often: |
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If Other, please specify:
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| How many bags of each size do you buy a month? Please input the number in the appropriate box. |
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| Cheese Snack Brand Bought Most Often: |
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If Other, please specify:
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| How many bags of each size do you buy a month? Please input the number in the appropriate box. |
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| Ready to Eat Popcorn Brand Bought Most Often: |
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If Other, please specify:
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| How many bags of each size do you buy a month? Please input the number in the appropriate box. |
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| Variety Pack Brand Bought Most Often: |
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If Other, please specify:
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| How many packs of each size do you buy a month? Please input the number in the appropriate box. |
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