574-2021Lep Details Question Title * 1. Internal Use Only Question Title * 2. Please fill the following details: Name Contact number Email address State Suburb Country of origin Year of Birth Occupation Question Title * 3. If you qualify for this study, you will require to provide your full address in order to receive some sample products to test and then you need to join a panel to provide your feedback regarding the products used. You are required to sign up with the new panel in order to be able to fill in the survey with your feedback and in order to be identified you are required to provide your driver's license details. QA. Do you agree with this? Yes No Question Title * 4. Can you please confirm that you are aged over 18 years and wish to complete this survey? Yes No Question Title * 5. Q7. What is your age? Younger than 18 years 18-20 21-24 25 – 29 30 – 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 64 65+ Please specify your exact age: Question Title * 6. Do you have a current Australian Drivers Licence? Yes No Question Title * 7. Do you have a current Medicare Card? Yes No Next
