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Please complete a profile on-line so that we can find a paid focus group that suits your interests.

If you have any questions, feel free to call us at: Advanced Focus 212.217.2000

Your demographic information is kept in strict confidentiality!

General Information

First name

 *

Last name

 *

Home phone

 *

Work phone

 Extension

Cell phone

Fax

Email

 

 

Home Address

 *

City

 *

State

 *

Zip

 *

Gender

 *

Marital Status

 *

Date of birth

  *

Ethnicity

 *

Education

Household income

Personal Income

Type of Housing

Political Party

Sexual Orientation

 

 

 

Children's Information

If you have children under the age of 18 living in your home, please complete the following

Gender

Date of birth  

Gender

Date of birth  

Gender

Date of birth  

Gender

Date of birth  

Gender

Date of birth  

Gender

Date of birth  

 

 

Employment Information

What is your employment status?

 *

Job title

Employer's name

Position

Number of employees who report to you

Industry

Your company's annual sales

Number of employees locally

Number of employees world-wide

Number of computers at your workplace

 

 

Travel

Do you travel for pleasure?

Type of pleasure travel

Do you travel for work?

Type of work travel

 

 

Computer & Technology

Do you use a computer at home?

Type(s) of computer (Hold the <ctrl> key down to select/unselect multiple responses)

Internet connection

On-line service provider

 

 

Do you use a computer at work?

Type(s) of computer (Hold the <ctrl> key down to select/unselect multiple responses)

 

 

Do you use a PDA?

Brand of PDA

 

 

Do you play computer or video games?

Type(s) of computer/video games (Hold the <ctrl> key down to select/unselect multiple responses)

 

 

Which of the following electronic devices do you own? (Hold the <ctrl> key down to select/unselect multiple responses)

 

 

What type of TV reception do you have?

 

 

Vehicles

Please indicate your 2 newest automobiles.

 

 

Make

Model

Year

Make

Model

Year

 

 

Telephone Service

Local telephone provider

Long distance provider

Cell Phone provider

 

 

Medical Information

Do you have any of the following medical conditions? (Hold the <ctrl> key down to select/unselect multiple responses)

Do you wear or use any of the following?(Hold the <ctrl> key down to select/unselect multiple responses)

What type of health insurance do you have?

 

 

Other Information

What type(s) of credit cards do you have?(Hold the <ctrl> key down to select/unselect multiple responses)

What type(s) of music do you listen to?(Hold the <ctrl> key down to select/unselect multiple responses)

Do you smoke cigarettes?

Primary brand

Type of cigarette

What type(s) of pets do you have? (Hold the <ctrl> key down to select/unselect multiple responses)

What type(s) of beverages do you drink? (Hold the <ctrl> key down to select/unselect multiple responses)

 

 

 

 

Referral Source

How did you hear about us?

 

 

 

 

 

 

 

National Recruiting Headquarters 38 East 29th Street, 7th Floor • New York, N.Y. 10016 • telephone:212.217.2000 fax:212.217.2007
The Facility 373 Park Avenue South, 8th Floor • New York, N.Y. 10016 • telephone:212.684.2000 fax:212.684.2677