*Paid Focus Group Inquiry Form* Question Title * 1. Full Name (Required.) First Name Last Name Question Title * 2. Telephone Question Title * 3. Email Question Title * 4. Gender Female Male Other Question Title * 5. Age Question Title * 6. Ethnic Group Question Title * 7. Highest Level of Education High School Some College College Grad Post Grad Question Title * 8. Occupation / Industry Question Title * 9. What state do you reside in? Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia (DC) Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Question Title * 10. City of Residence Question Title * 11. County of Residence Question Title * 12. Todays Date Date Date Done