Application to BeAware as test household
Exit this survey

1. Enter your details

Please provide the information requested below. You will be contacted by email to participate in the recruitment.

*
1. Full name

Full name

*
2. Age

Age

*
3. Email address

Email address

*
4. Municipality of residence

Municipality of residence

*
5. Do you have a flat rate broadband or ADLS contract?

Do you have a flat rate broadband or ADLS contract? Yes

*
6. Please describe your family

	Add number of members
Number of adults in your family	Please describe your family Number of adults in your family Add number of members
Number of children (0-10 years old)	Number of children (0-10 years old) Add number of members
Number of children (11-18 years old)	Number of children (11-18 years old) Add number of members

DATA PROTECTION:
Information on data protection (art. 13 of Italian bye-law 196/2003): all personal data processed is treated with due care and diligence as per the provisions of the law 196/2003 and subsequent changes and additions and used only for the purpose of the recruitment"

*
7. I confirm to having read the information provided regarding Data Protection and consent to my details being used for the relevant purposes

I confirm to having read the information provided regarding Data Protection and consent to my details being used for the relevant purposes Yes

Application to BeAware as test householdExit this survey

1. Enter your details

*1. Full name

*2. Age

*3. Email address

*4. Municipality of residence

*5. Do you have a flat rate broadband or ADLS contract?

*6. Please describe your family

*7. I confirm to having read the information provided regarding Data Protection and consent to my details being used for the relevant purposes