Join Our Database

1. Please select your gender *  Please select a response Male Female

2. What is your current marital status? *  Please select a response Married/Living With Partner Single Divorced/Separated Widowed

3. Would you like your spouse to be entered into the database as well? *  Please select a response Yes No
  If no, skip to question 9

4. What is your spouse's name?

5. What is your spouse's birthdate?   MM/DD/YY

6. How would you classify your spouse's current employment?  Please select a response Full-time (More than 30 hours a week) Part-time (Less than 30 hours a week) Self-employed Not Employed
If your choice is Not Employed, skip to question 9

7. In what industry does your spouse work?

8. What is your spouse's position or title?  Please select a response President/CEO/Owner/Partner Vice President/Senior VP/Executive VP Senior Management/Director Attorney/Lawyer Physician Financial Advisor Architect/Graphic Designer Human Resources Information Technology/Software Middle Management Other Management Sales/Marketing Hourly Worker Other

9. How would you classify your current employment? *  Please select a response Full-time (More than 30 hours a week) Part-time (Less than 30 hours a week) Self-employed Not Employed
If your choice is Not Employed, skip to question 10

10. In what industry do you work?

11. What is your position or title?  Please select a response President/CEO/Owner/Partner Vice President/Senior VP/Executive VP Senior Management/Director Attorney/Lawyer Physician Financial Advisor Architect/Graphic Designer Human Resources Information Technology/Software Middle Management Other Management Sales/Marketing Hourly Worker Other

12. What is the highest level of education you have completed? *  Please select a response Some high school or less High school graduate Some college Two-year College/Technical School Graduate Four-year college graduate Some post-graduate work Postgraduate degree

13. Which of the following describes your current residence? *  Please select a response Own - Single Family Own - Condo/Townhouse Own - Mobile Home Rent - Single Family Rent - Condo/Townhouse Rent - Apartment Rent - Mobile Home Living rent free Other
If your choice is Other, please specify

14. Does anyone in your household work on remodeling projects in your home? * Yes No

15. Which of the following categories best describes your total, annual household income, before taxes? *  Please select a response Less than $20,000 More than $20,000 but less than $35,000 More than $35,000 but less than $50,000 More than $50,000 but less than $75,000 More than $75,000 but less than $100,000 More than $100,000 but less than $125,000 More than $125,000 but less than $150,000 More than $150,000

16. Which category represents your ethnic background?  Please select a response African American Asian/Pacific Islander Caucasian Middle Eastern Native American/American Indian Other
If your choice is Other, please specify

17. Do you currently use a desktop computer or laptop?  Please select a response Desktop Computer Laptop Computer Both a Desktop and a Laptop Neither

18. Is the computer you use a Mac or PC or do you use both?  Please select a response Mac PC Both

19. Do you have access to the Internet? Yes No

20. Have you ever made any purchases online? Yes No   If no, please skip to question 22

21. How often do you purchase online?  Please select a response Weekly Monthly Less than once a month A few times a year

22. What kinds of activities do you do on the internet?
(Please check all that apply) Online Banking/Pay Bills
Book Travel
Chat Rooms
Research products/Services
Online games/Downloading music and videos
Research financial information
Research medical information

23. We sometimes conduct research studies with people who have various health conditions. Do you, or someone living in your household, have and of the following health conditions?
(Please check all that apply) Heart Disease
Diabetes Type I
Diabetes Type II
Arthritis
Asthma
Back Pain/Neck Pain
Depression
Other
If your choice is other, please specify

24. Including yourself, how many people are in your household? *  Please select a response One Two Three Four Five Six More than Six

25. Because we sometimes conduct market research on behalf of companies for children's products,
please provide the gender and date of birth for up to six children in your household.

No children in household
I prefer not to answer

Child 1 Male Female   MM/DD/YY

Child 2 Male Female   MM/DD/YY

Child 3 Male Female   MM/DD/YY

Child 4 Male Female   MM/DD/YY

Child 5 Male Female   MM/DD/YY

Child 6 Male Female   MM/DD/YY

26. Are your children enrolled in public or private school, or are they home-schooled?
(Please check all that apply) Public School
Private School
Home-schooled

We will add your number to our database and call you from time to time to see if you are interested and qualified to participate in a market research study where you are paid for your time.

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