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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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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:

Are you employed:

Occupation?

Job Title?

Party Affiliation:

Is your total household income:

Spouse’s Employment Status:

Spouse’s Occupation:

Do you own cat, dog or other pet? (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)

Do you smoke?

Do you have?

Satellite TV

Cable TV

What genres of music to you regularly listen to? (Specify which; Hold the <ctrl> key down to select/unselect multiple responses)

Which banks do you use? (Specify which; Hold the <ctrl> key down to select/unselect multiple responses)

What brand of computer do you have at home?

 

 

Do you own a home-based business?

What’s your fax #?

Email Address

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Home Address (including city & zip):

Address

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City

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State

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Zip

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County

Do you own, rent, or live with your parents?

Please list the Date of Birth & Gender of each child under Age 18
(please use mm/dd/yy format for the birthdate)::

Child 1

 

Birthdate:

Gender:

Child 2

 

Birthdate:

Gender:

Child 3

 

Birthdate:

Gender:

Child 4

 

Birthdate:

Gender:

Child 5

 

Birthdate:

Gender:

Child 6

 

Birthdate:

Gender:

Please list the year, make and model of the 2 primary vehicles owned by your household.

Make

Model

Year

Make

Model

Year

Promo Code:


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Fieldwork and its clients rely on the integrity of focus group respondents to conduct accurate and meaningful research.

We ask that you commit to the following:

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  • Be truthful in answering questions about yourself and your habits.
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  • Understand that anyone arriving late for their appointment may not be admitted into the study or be compensated.
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Panelists under the age of 18 must have a Parent or Guardian's permission to participate.

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