Automotive Research Study

Thank you for your interest in our automotive research study.

Dependent on your qualification you may be asked to either participate in an in-home portion that pays $350 or a focus group at a local facility in Rutherford, NJ that pays $200. The duration for both are 3 hours, however the requirements are different.

Based on your responses below, if you qualify, one of our staff members will contact you to ask you a few questions. If you qualify based on those questions, we will schedule you accordingly.

Thank you for your time

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* 1. Please indicate your current age

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* 2. Please indicate your gender

Male

Female

Other

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* 3. Who is your current household comprised of?

Single, living alone

Living with parents (with or without significant other)

Living with spouse/significant other

Living with significant other and child(ren)

Living with child(ren)

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* 4. If you have a child or children currently living with you, please indicate the age of each child below. **If under 1 year of age, please indicate 0. If no children, please skip.

Child 1

Child 2

Child 3

Child 4

Child 5

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* 5. Please indicate the make of your primary vehicle

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* 6. Please indicate the model of your primary vehicle

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* 7. Please indicate the model year of your primary vehicle

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* 8. Please provide the VIN number of your primary vehicle

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* 9. If applicable, please indicate the make of your secondary vehicle

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* 10. If applicable, please indicate the model of your secondary vehicle

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* 11. If applicable, please indicate the model year of your secondary vehicle

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* 12. If applicable, please provide the VIN number of your secondary vehicle

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* 13. If you pre-qualify, one of our staff members will contact you. Please provide your contact information

First Name *

Last Name *

ZIP/Postal Code *

Phone Number *

Alternate Phone Number

Email Address *