Focus Group Research: Financial Planning

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* 1. What is your First Name?

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* 2. What is your Last Name?

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* 3. What is the best phone number we can reach you at?

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* 4. What is your email address?

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* 5. What is your gender?

Male

Female

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* 6. What is your age?

Under 20

20 to 29

30 to 39

40 to 49

50 or over

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* 7. What is your current relationship status?

Married / Common law

In a relationship

Single, never married

Divorced / Widowed

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* 8. What is your employment status? Are you…?

Working full time

Working part time

Self-employed

A full or part-time student

A full-time homemaker

Currently unemployed, and actively looking for work

Retired

Other (please specify)

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* 9. Are you responsible for managing your personal and/or household finances?

Yes, I am primary responsible

Yes, I am jointly responsible

No, I am not responsible

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* 10. Do you have any children who live with you full-time? Would you say…?

Yes, I have at least one child who lives with me

Yes, I have child(ren) but they do not live with me

No, I have no children

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* 11. To enter our draw for a FREE iPad, include the names and numbers of some people that would be interested in getting paid for their opinions! (Remember, each referral earns you one ballot.)

Referral Name 1:

Referral Phone Number 1:

Referral Name 2:

Referral Phone Number 2:

Referral Name 3:

Referral Phone Number 3: