Elektro 87 SURVAY
                             TEXT VERSION
     =================================================================

     What do you think about my homepage ?
                          [] Amazing....
                          [] Fair enough
                          [] So so...
                          [] Trash bag please!
     How do you find this page ?
                          [] Just Surf on It
                          [] Friend
                          [] Links
                          [] MailingList
                          [] Newsgroup
                          [] Search Engine
                          [] Word of Mouth
                          [] Other Media



     About you :
     ===========
     Full Name            : __________________________________________
     E-mail Address       : __________________________________________
     Homepage             : http://___________________________________
        Second URL        : http://___________________________________
     Company Name         : __________________________________________
     Department           : _______________________
     Title                : _______________________
     Address              : _______________________
     City                 : _______________________
     State                : _______ ZIP : _________ 
     Country              : _______________________
     Contact Phone        : (___)_________
        Other Phone       : (___)_________
     Fax.                 : (___)_________
     Age                  : ______ years old
     Sex                  : [] Male [] Female
     Spouse Name          : __________________________________________
     Children's Name      : __________________________________________
     Children's Name      : __________________________________________
     Children's Name      : __________________________________________

     Browser Name         : _______________________
     Operating System     : _______________________
     Computer             : _______________________
     Do you wish to be listed in my Elektro mailing list ? []Yes []No
     Suggestion and Comments : 
     _________________________________________________________________
     _________________________________________________________________
     _________________________________________________________________
     _________________________________________________________________
     _________________________________________________________________

     Thank you for your input.

     =================================================================
     Please complete this form and send it by email
     to ihadianto@bigfoot.com
     =================================================================