Chicago - Epilepsy - May 2018

Intro Section

Plaza Research Chicago is conducting a face to face interview for Males & Females ages 15-65 years old. This face to face interview will be held on May 8th at various times throughout the day If you qualify and participate, you will receive $150 for 1 hours 20 Minutes of your time.

If you're interested please fill out the questions below.

Due to the large response to our surveys, we are only able to contact those that look like a match. Please continue to answer future studies, as you may be a match to those.

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* 1. Please provide us with the following information. We will be contacting you by telephone if you seem like a match.

Name:

ZIP:

Email Address:

Phone Number:

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* 2. Alternate Contact number

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* 3. What is your date of birth?

Date

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* 1. Please provide us with the following information. We will be contacting you by telephone if you seem like a match.

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* 2. Alternate Contact number

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* 3. What is your date of birth?

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* 4. What is your age?