Questionnaire

This simple questionnaire applies to anyone interested in ManGo Solutions Membership Programs.

Please ensure all information is filled out accurately so the appropriate ManGo representative can respond to you as quickly as possible.

* required fields

Today's Date • Fri, Jul 30, 2010
First Name * Last Name *
Age
Province / Territory * City *
Contact Number * E-Mail Address *
What is your current occupation?
Are you currently self-employed?
 Yes  No
Are you currently incorporated?
 Yes  No
Company Name
Do you have a spouse or co-dependant?
 Yes  No
Do you have any dependants?
 Yes  No
Do you receive any medical benefits from your current employer?
 Yes  No
Do you receive any medical benefits from your spouses employer?
 Yes  No
Do you or your spouse have a personal health or dental plan?
 Yes  No
Do you have a personal life insurance policy?
 Yes  No
Do you have a critical illness insurance policy?
 Yes  No
Do you have a personal disability insurance policy?
 Yes  No
Do you have a personal liability insurance policy?
 Yes  No
Do you have home and content insurance?
 Yes  No
Do you have auto insurance?
 Yes  No
Do you have a legal will?
 Yes  No
Did you file personal income tax last year?
 Yes  No   If No, have you filed in the last
Approximately, what is your gross annual income?
     Privacy Statement **

Privacy Statement

** The contents of this communication, including any attachment(s), are confidential and may be privileged information. If you are not the intended recipient (or are not receiving this communication on behalf of the intended recipient), please notify the sender immediately and delete or destroy this communication without reading it, and without making, forwarding, or retaining any copy or record of it or its contents.

Thank you.