Field Research, Inc.

	High Quality Medical and Consumer Market Research

Consumers

If you are interested in participating in our surveys and focus groups, please fill in the form below. We speak to consumers, such as yourself, regarding products and services. These products and services may be currently on the market or under development. The information you provide is for our demographics only and you will only be contacted if you match our criteria.

General Information

First Name:

Last Name:

Address:

City:

State:

Zip Code:

Home #:

Work #

Work Extension:

Cell #:

Fax #:

Email:

Occupation:

Industry:

(If retired) Former Occupation:

(If retired) Former Field:

Marital Status

Single Married Widowed Separated Divorced Alternative Lifestyle

Gender

Male Female

Number of Domestic Work Trips per Year:

Number of International Work Trips per Year:

Date of Birth:

Ethnicity:

Caucasian Asian African American Hispanic Other

Education

High School Some College College Graduate Graduate Degree Trade School

Household Income

Under $25,000 $25,000 - $34,999 $35,000 - $49,999 $50,000 - $74,999 $75,000 - $99,999 $100,000 - $149,999 $150,000 +

Housing Status:

Housing Type:

Children

# of male children:
Male Children's Name:	Birth Date

# of female children
Female Children's Name	Birth Date

Computers/Internet

Brand of computer used at home:

On-Line Providers:

Internet Connection Speed:

Dial-up DSL Cable T1

Electronics Owned

Electronics:

XBox 360 Nintendo Wii Play Station 3 MP3 Player Laptop Digital Camera Plasma TV LCD TV DLP TV Flip Video PSP Game Boy/Nintendo DS N-Gage Other

Telephone Information

Cell Phone Provider:

Cell Phone Brand:

Cell Phone Model:

Local Telephone Carrier:

Long Distance Carrier:

Miscellaneous Information

Cigarette Brand:

Type of Cigarette:

Regular Menthol Lite Ultra Lite

Number of packs per day:

Television Provider:

Do you drink any of the following beverages?:

Beer Wine Spirits/Mixed Drinks Cordials/After Dinner

Pets

What types and ages of pets do you own?

Medical Conditions

Do you have any medical conditions? Please list/describe them:

Prescription Medications you are taking?

Credit cards owned:

I agree to provide Field Research with this information for purposes of participation in market research events. This information will not be used for any other purposes and will be kept strictly confidential.

High Quality Medical and Consumer Market Research