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1.
What is your name?
(Required.)
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2.
What is the best phone number for us to contact you on?
(Required.)
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3.
Email Address:
(Required.)
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4.
Are you CURRENTLY scheduled to participate in a paid marketing research study with us?
(Required.)
Yes
No
I'm not sure
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5.
What is your gender?
(Required.)
Male
Female
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6.
What is your age?
(Required.)
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7.
What is your 5 digit ZIP code?
(Required.)
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8.
Which of the following best describes your ethnic background?
(Required.)
African American
Asian
Caucasian
Hispanic/Latino
Native American
Other
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9.
Which of the following best describes your employment situation?
(Required.)
Employed full time outside the home
Employed inside the home
Employed part-time
Homemaker
Not employed
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10.
How many children under 18 do you have living at home with you?
(Required.)
0
1
2
3
4
5
6+
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11.
What is the highest level of education you have had the opportunity to complete?
(Required.)
Some high school
High school graduate
Trade or technical school
Some college
College graduate
Post graduate degree
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12.
Into which of the following ranges does your annual household income fall?
(Required.)
Less than $25,000
$25,000-49,999
$50,000-74,999
$75,000-99,999
$100,000-150,000
Over $150,000
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13.
What industry do you work in?
(Required.)
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14.
What is your job title?
(Required.)