First Name Username Password Confirm Password Address Suburb Postal Code GenderMaleFemaleOtherDo you have any children under the age of 18 living at home?YesNoChildrens Ages - Girls - select all that applyLess than 1 year1 - 2 years3 - 4 years5 - 8 years9 - 12 years13 - 17 yearsEthnicityNew Zealand EuropeanMaori / Pacific IslanderAustralianEuropeanIndianAsianAmericanCanadianSouth AfricanOtherPhone iPhoneAndroidOtherMobile ProviderVodafoneSpark2 DegreesOtherMobile PlanPre-PayPlan ContractMonthly - No ContractDo you have any pets?DogCatBirdFishHorseOtherWhat is your Instagram Name? Last Name E-mail Address Birth Date City / Town What is your relationship status?SingleMarriedCivil UnionDeFactoSeparated / DivorcedIncluding yourself, how many people are in your household?12345+Childrens Ages - Boys - Select all that applyLess than 1 year1 - 2 years3 - 4 years5 - 8 years9 - 12 years13 - 17 yearsWhat stores do you regularly purchase from?CountdownPak n SaveNew WorldFresh n SaveMad ButcherFarmersThe WarehouseKMartTrade MeMitre 10WhitcoullsBriscoesBinn InnHarvey NormanOtherHow often do you shop for groceries? DailySeveral Times a WeekOnce a WeekOnce a FortnightMonthlyDiet/Preferences - select all that apply CoeliacMostly gluten-freeDairy FreeDiabeticSugar FreeNatural SweetenersFree RangeNZ MadeNut AllergyOrganicPaleoVegetarianProtein (High Protein Foods or Foods with Protein Added)No Specific Diet PreferencesOn average, how much do you spend on groceries per week? 50-100100-200200-300400-500600-1000above 1000Which, if any, of these drinks have you consumed in the past four weeks?BeerWineSpiritsEnergy DrinksCoffeeTeaCarbonated soft drinksFruit drinks/juicesBottled waterI don't drink alcoholSkin TypeDry SkinSensitive SkinOily SkinSensitive SkinNormal SkinInterests/Lifestyle - select all that applyGym / Health & FitnessFashionTravelHome DIYHome GardenerSportsBeauty / CosmeticsCarsOnline ShoppingI understand and agree that receipt of a SAMBOX NZ is not guaranteed, and that I may cancel my account at anytime by contacting SamboxNZ. I also have read and agree to the Privacy Policy and Terms and Conditions Only fill in if you are not human
