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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.

OCCUPATION INFORMATION

Employer:

Occupation:

Bus Phone:

Ext:

Do you work:

Work 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:

Sexual Orientation:
Country of Birth:
Education:
Housing:
Number of children living at home: *

1. Date of birth:  Gender:  M  F

2. Date of birth:  Gender:  M  F

3. Date of birth:  Gender:  M  F

4. Date of birth:  Gender:  M  F

5. Date of birth:  Gender:  M  F

6. Date of birth:  Gender:  M  F

Please list any medical conditions you might have:

(Select all that apply. Hold the <ctrl> key down to select/unselect multiple responses.)  

    

Do you smoke? Yes No

If yes, which brand?

Which of the following alcoholic beverages do you consume?

(Select all that apply. Hold the <ctrl> key down to select/unselect multiple responses.)

    

Please select your favorite radio stations (Please select no more than 4 stations).
(Select all that apply. Hold the <ctrl> key down to select/unselect multiple responses.)

 

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?
What is the primary language you speak at home?
Secondary language:

We conduct groups during the day and in the evening after working hours. Are you able to attend?   

Day groups    Evening Groups    Both

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