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Your Opinion Counts!

If you would like to be contacted occasionally and be paid for giving your honest opinion, positive or negative, please fill out the following information about yourself and your household.
 
Note: All the information in this form is and will remain strictly confidential. Your name will not be sold to any mailing lists. We will use this information as a guide to call you for paid focus groups and interviews ONLY. If you feel uncomfortable answering some questions, simply leave them blank; the more information we have, however, the easier it will be to find focus groups for which you may qualify. * denotes required fields.

  PERSONAL INFORMATION
 
  first:  *
  last:  *
  gender:  *
  home address:  *
  city:  *
  State:  *
  zip:  *
  phone:  *
  email:  *
  date of birth:
(mm/dd/yy): 		 *
    household annual income:
   
    marital status:
   
  OCCUPATION INFORMATION
 
  employer:
  occupation:
  bus phone:
  ext:
     
  do you work:
      full-time part-time unemployed
  work computer:
 
  features on your work computer:
      CD-ROM internet access email
     
how often do you travel for business(times per year):
    domestic:    international:

  MISCELLANEOUS INFORMATION
 
 
race: if other, please specify:
 
political party: if other, please specify:
 
education: housing:
number of children living at home:       *
  1.  date of birth:      gender:  M   F   3.  date of birth:      gender:  M   F
  2.  date of birth:      gender:  M   F   4.  date of birth:      gender:  M   F
 
please list any medical conditions you might have:
  Glasses/Contacts      Hearing      Diabetes     Other:  
 
do you smoke?  yes No     if yes, which brand?  
 
which of the following alcoholic beverages do you consume?
  None   Beer   Wine    Vodka    Scotch    Cognac    Rum    Gin    Brandy
 
please select your favorite radio stations (please select no more than 4 stations).
hold the <ctrl> key down to select/unselect multiple responses.
 
which of the following types of credit cards do you own and use?
  Visa        MasterCard       American Express        Discover
 
please describe the vehicle(s) you drive most often. (select all that apply)
hold the <ctrl> key down to select/unselect multiple responses.
year
make
model
 
which of the following best describes your home computer?
 
which of the following features does your home computer have?
  CD-ROM   internet access    DVD   email
 
which of the following electronic devices do you own?
  cell phone    video camera   digital camera   cable TV
 
we conduct groups during the day and in the evening after working hours. are you able to attend?
  day groups    evening Groups    both
 
what is the primary language you speak at home? 
 
secondary language: 

 
    

 
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