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First Name:

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Last Name:

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Primary Phone:

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Cell Phone (if different):

Work Phone:

Email:

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Address: *
City: *
State: *
Zip: *

County:

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Date of Birth: 

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Gender:

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Race:

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Highest grade of education:

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Marital Status:

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Total household income:

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Employment Status:

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What industry do you work for?

Job Title/Occupation:

Are you a decision maker for your company?

Spouse’s Employment Status:

Spouse’s Job Industry:

Number of children under 18 living at home:

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Party Affiliation:

Housing Situation:

Do you speak Spanish and English?

Do you have a Dog or Cat?

Do you use any Tobacco products? (Specify which; Hold the <ctrl> key down to select/unselect multiple responses)

Do you consume Beer regularly?
(Specify which; Hold the <ctrl> key down to select/unselect multiple responses)

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

Does anyone else in your household suffer from any of the following?
(Specify which; Hold the <ctrl> key down to select/unselect multiple responses)


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We ask that you commit to the following:

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  • 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.
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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.