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*First Name: 

*Last Name:

*Home Phone #:

Area Code

Number

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If you only have a cell phone, and no land line, please check this box:

 

*Address:

 

(This must be your home address. Please do not enter a Post Office Box or Work address.)

*City:

*US State, Canadian Province or Puerto Rico:

*Zip:

*Which area would you like to participate in Focus Groups?

*Date of Birth:

*Gender:

Ethnic Background:

Country of Birth:

Marital Status:

Education:

Religious Preference:

 

 

For each of the next three fields, please  specify the phone number, where appropriate.

 

Area Code

Number

 

 

 

 

Work Phone

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Cellular Phone

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Fax Machine

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E-Mail Address:

Please note: by entering an e-mail address or phone number, you are giving us your consent to send you e-mails or call you on the numbers provided, utilizing our callback system, for Market Research studies you may be interested in.

 

 

 

Occupation Information

Employment:

 

Are you a student?

 

 

 

Bank:
(Select all that apply. Hold down the <Ctrl> key while clicking to make multiple selections)

 

 

 

Average Number of Business Trips by Air per Year:

Average Number of Pleasure Trips by Air per Year:

 

 

 

Do you drink...
(Select all that apply. Hold down the <Ctrl> key while clicking to make multiple selections)

Do you smoke?

 

 

 

Are you registered to  vote?

Registered Political Affiliation:

 

 

 

Housing Information

Living Arrangements

Type of Housing

Do you have a Computer?
(Select all that apply. Hold down the <Ctrl> key while clicking to make multiple selections)

Do you play any video games?
(Select all that apply. Hold down the <Ctrl> key while clicking to make multiple selections)

Do you have any pets?
(Select all that apply. Hold down the <Ctrl> key while clicking to make multiple selections)

 

 

 

Do you have...

Cable TV

Satellite TV

FiOS TV

 

 

 

Your Average Annual Household Income before taxes

How did you hear about us?

 

 

 

Household Vehicles (including motorcycles):
Make = Manufacturer (Ford, Toyota, Mercedes, Hyundai, Nissan, etc.)
Model = Version of Car.  (Explorer, Mustang, Corolla, etc.)
(For each vehicle, all fields are required.)
 

Make

Model

Year

Purchased

Driven By

Make

Model

Year

Purchased

Driven By

Make

Model

Year

Purchased

Driven By

 

Make

Model

Year

Purchased

Driven By

 

 

 

Languages

 

 

Which of the following languages, in addition to English, do you speak?
(Select all that apply. Hold down the <Ctrl> key while clicking to make multiple selections)

 

 

 

Children Living In Household

We often conduct toy and television program research with children. If there are any children under the age of 18 living in the household, please click below:



 

 

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