FIRST NAME: LAST NAME: EMAIL ADDRESS: AGE: CITY: Select a City Toronto Mississauga Durham Hamilton Simcoe Ottawa Calgary Edmonton Winnipeg Vancouver London Montreal Other TELEPHONE: ANNUAL INCOME: GENDER: Select Income $0 - $35 000 $35 000 - $50 000 $50 000 - $75 000 $75 000 - $150 000 $150 000 + Female Male HOW DID YOU HEAR ABOUT US? How did you hear about us? Television Radio Billboard Print Mail Survey Keyword Search Banner Ad Yellow Pages Event Friend Other (This questionnaire is strictly confidential.)

Please tell us how we are doing. FIRST NAME LAST NAME EMAIL ADDRESS CITY HOW ARE WE DOING? Please tell us about your referral. REFERRAL NAME WAS PHONE CONTACT MADE? Yes No HOW MANY CALLS? DID YOU MEET? Yes No IF NOT, TELL US WHY YOU DIDN'T MEET WHAT QUALITIES DID YOU ENJOY ABOUT YOUR REFERRAL? WHAT QUALITIES WOULD YOU CHANGE ABOUT YOUR NEXT REFERRAL? SHARE WITH US THE HIGHLIGHTS OF YOUR EXPERIENCE PLACE MY FILE ON HOLD I AM READY FOR ANOTHER REFERRAL Yes No Yes No IF YES, PLEASE INCLUDE YOUR REASON FOR GOING ON HOLD

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