Serial Number :
Your Name :
E-Mail Address :
Phone Number :
Address :
City :
State :
Zip :
Operating System :
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Windows VISTA
Windows XP
Windows 2000
Mac OS X 10.2
Mac OS X 10.3
Mac OS X 10.4
Mac OS X 10.5
Other
Place of Purchase :
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Wild Divine Website
Other Website
Retail Store
Professional Office
Tradeshow
Seminar / Workshop
Gift
Sex :
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I choose not to answer
Male
Female
Age :
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I choose not to answer
Under 18
18 - 25 years
26-35 years
36-45 years
46-55 years
56-65 years
65 plus years
Education :
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I choose not to answer
High School
Some College
Under Graduate Degree
Graduate Degree
Doctorate
Household Income :
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I choose not to answer
- - - -
< $25,000 per year
$25 - $35,000 per year
$36 - $50,000 per year
$51 - $75,000 per year
$76 - $100,000 per year
$101 - $150,000 per year
>$150,000 per year
Main Interest in The Journey :
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I choose not to answer
Meditation
Breathing Exercises
Reduce Stress
Improve Physical Health
Spirituality
Gaming
Technology
Entertainment
Therapy
Gift
Music
Other
Did you purchase the game for yourself? :
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I choose not to answer
Yes, I intend to be the primary user.
No, it's a gift for an adult family member.
No, it's a gift for a child.
No, it's a gift for a friend.
No, it's a corporate gift.
No, I intend to use it with my patients.
Other
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