Census Information
PLEASE COMPLETE THE FORM BELOW WITH YOUR PERSONAL INDIVIDUAL INFORMATION.
ONE NAME PER SUBMISSION PLEASE.

(ALL INFORMATION IS CONFIDENTIAL AND WILL NOT BE SHARED WITH ANYONE OUTSIDE
OF THREE SQUARES AND A STAR MGMT GROUP AND ITS DIRECT BUSINESS PARTNERS)

First Name *
Your answer
Middle Initial
Your answer
Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Sex *
Street Address *
Your answer
Address Line 2
Your answer
City *
Your answer
State (e.g. AL, AK, AR, CA, etc.) *
Your answer
Zip Code *
Your answer
Phone Number (### - ### - ####) *
Your answer
Email Address
Your answer
Organization Name *
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