Thank you for expressing interest in joining our database!

Please be careful to answer all questions - leaving anything unanswered could leave out essential information in selecting participants for specific projects. Your information is securely transferred to our systems and personally identifiable information is never shared with anyone else. Your voluntary participation in Market research with Fieldwork constitutes an Independent Contractor relationship, not an Employment relationship.

If at any time you wish to unsubscribe from our database, you may call the office you signed up with or fill out this unsubscribe form.

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

First Name:

*

Last Name:

*

Home Phone:

*

May we call you at work?

If yes, what is the number:

Do you have a Cell phone?

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

What’s your email address?

*

Home Address (including city & zip):

Address

*

City

*

State

*

Zip

*

Where are you willing to participate in a market research study?

Date of Birth:

  *

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

Race:

Gender:

Marital Status:

Highest grade of education completed:

Are you employed:

Occupation?

Job Title?

Are you self-employed?

Do you own a home-based business?

Party Affiliation:

Is your total household income:

Is your spouse employed?

Spouse’s Occupation:

Do you own a cat, dog or other pet?

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

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

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

At home, which do you have:

Do you own a: (Specify which; Hold the <ctrl> key down to select/unselect multiple responses)

Do you primarily drive a:

What is the make, model and year of your primary vehicle?

Make
 
Model
 
Year

Do you have a Computer for home use?

Are you Online at home?  Is it high-speed access? If high speed is it cable or modem?

Who is your Online Provider at home?

Who is your cell phone provider?

What’s your fax #?

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

Please list the Date of Birth & Gender of each child:

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:
 

How did you hear about us?

Promo Code:


What are my responsibilities as a focus group participant?

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:
  • 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.