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The Question Shop Add Sheet
  1. Please complete the following electronic registration form so that you will be eligible to participate in paid marketing research projects. Our projects include focus group discussions, one on one interviews, online surveys, in home interviews, and/or phone surveys.

    You can also be added to our database by calling (714) 974-8020.

    Please be ensured that all data you provide is fully protected and is 100% confidential. All information that we collect on this form is used only to help select consumers for market research projects. We do not sell or make available to anyone outside The Question Shop, Inc., the names, phone numbers, or email addresses of respondents in our database.

    We are proud members of the M.R.A. (Marketing Research Association) and abide by the laws of C.M.O.R. (Code of Marketing Research Standards).

    Thank you for your participation. YOUR OPINION COUNTS!

  2. Please fill out the following form to be considered for participation in research projects.
    ALL fields are required.

  3. Your Personal Contact Information
  4. First Name
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  5. Last Name
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  6. Address
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  7. City
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  8. Zip Code
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  9. Home Phone
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    Please enter phone number in format: 123-456-7890
  10. Work Phone
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    Please enter phone number in format: 123-456-7890
  11. Cell Phone
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    Please enter phone number in format: 123-456-7890
  12. E-mail
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  13.  
  1. Your Background Information
  2. Date of Birth
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  3. Gender
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  4. What is your ethnicity?
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  5. What is your marital status?
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  6. What is your highest level of education?
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  7. What best describes your yearly gross household income?
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  8. Are you registered to vote?
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  9. Do you smoke cigarettes?
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  10. Do you drink beer on a regular basis?
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  11. Do you drink wine on a regular basis?
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  12.  
  1. Your Occupation Information
  2. What is your employment status?
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  3. What is your occupation title? (Please be specific)
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  4. Do you consider yourself to be White/Blue collar?
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  5. What industry best represents your work?
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  6. Company Employee Size
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  7.  
  1. Your Household Information
  2. What form of housing do you currently live in?
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  3. Do you own or rent?
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  4. Do you have any of the following pets?
  5. Birds
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  6. Dogs
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  7. Cats
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  8. Other Pets
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  9. Do you have any children under age 18?
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  10. If you have children under 18, please list the gender and birth date of each child.
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    Example:
    Female, 10/05/1999
  11. Please list your TWO favorite radio stations for music.
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  12. Do you have any of the following medical conditions?
  13. Allergies
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  14. Hearing Loss
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  15. High Blood Pressure
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  16. High Cholesterol
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  17. Asthma
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  18. Anemia
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  19. Diabetes
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  20. Migraines
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  21. Arthritis
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  22. Cancer
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  23. Do you own any of the following vehicles?
  24. ATV
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  25. Dirt Bike
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  26. Motorcycle
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  27. Personal Watercraft
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  28. RV
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  29. Please list the year, make and model of the TWO primary vehicles you drive.
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  30.