October 12, 2008

Name:		Home Phone:
Email:		Work Phone:
		Cell Phone:
		Fax number:
Address:
City:
State:	Zip:
Gender:	-Select- male female	Age:	-Select- 20-30 31-40 41-50 51-60 Over 61

Available Monday thru Friday (10am - 4pm)	Yes No
Car #1: Year Make: Model: Car #2: Year Make: Model:
Do you have a spouse or friend who can accompany you? -Select- Friend Spouse Both Neither
Do you have experience using hidden video equipment?	Yes No
If so: What type of experience do you have?
What type of hidden camera equipment have you used?
Do you have your own camera equipment?	Yes No
If so, please describe:
What regional areas are you willing to drive?
Will you travel to other cities/states?	Yes No
If so, can you take on assignments lasting 2-3 days?	Yes No
Other information about yourself, experience, etc.