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(Fields marked with an asterisk "*" are required)
 

First Name:

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Last Name:

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Home Phone:

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May we call you at work?

If yes, what is the number:

If you have a cell phone & we can call you on it please write it here:

Date of Birth:

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Race:

Gender:

Marital Status:

Highest grade of education completed:

Political party:

Are you employed:

What is your job title?

How many people work for this company at your location?

How many people work for this company  overall?

What’s your fax #?

What’s your email address?

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Is your total household income:

Do you own any pets?

Do you suffer from any of the following? (Specify which; Hold the <ctrl> key down to select/unselect multiple responses)

Do you have any diet restrictions? (Specify which; Hold the <ctrl> key down to select/unselect multiple responses)

Do you smoke?

What make and year of the primary vehicle you personally drive?

Make:

Year

At home, which do you have:

Home Address (including city & zip):

Address

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State

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City

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Zip

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Promo Code:

Do you own a single family home or a condo or rent? Do you live with your parents?

Please list the Name, Date of Birth & Gender of each child under age 18 in your household:

Child 1

First Name:

Birthdate:
 

Gender:

Child 2

First Name:

Birthdate:
 

Gender:

Child 3

First Name:

Birthdate:
 

Gender:

Child 4

First Name:

Birthdate:
 

Gender:

Child 5

First Name:

Birthdate:
 

Gender:

Child 6

First Name:

Birthdate:
 

Gender:

What location in the Chicago area do you prefer?


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We ask that you commit to the following:

  • Providing your personal information to Fieldwork constitutes your express written consent for collection, storing and processing your personal information.
  • Be truthful in answering questions about yourself and your habits.
  • Arrive for your appointment at least 15 minutes early and be ready to fully participate in the discussion.
  • Understand that anyone arriving late for their appointment may not be admitted into the study or be compensated.
  • Notify fieldwork if you must cancel with as much advance notice as possible. Both fieldwork and our clients are depending on your participation, and while we understand that circumstances may come up forcing you to cancel, with advance notice, we have the opportunity to try to recruit another interested participant.
  • Enjoy & contribute to the discussion! Focus Groups are fun and your opinions count!
Panelists under the age of 18 must have a Parent or Guardian's permission to participate.

*  I have read and understand my responsibilities as a participant and I agree to the terms and conditions above.