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Please begin by filling in your contact information below. Then, please indicate the typesof research for which you would like to be contacted. If you have any questions, please call Axiom Research at 901-821-4333.

 
     
     
Step1: Please provide your contact information.
(Name and one email address required)
   
First Name Last Name
   
Street Address Apartment or Unit # (if applicable)
   
City State & Zip
   
Home Phone (000-000-0000) Cell Phone
   
Work Phone  
 
   
Email Address #1 Confirm Email Address #1
   
Email Address #2 Confirm Eamil Address #2
   
   
  Step 2: For what types of studies would you like to be contacted?
   
Focus Groups  
Telephone Surveys  
Online Surveys  
Online Panels  
Product Placements  
Taste Tests  
   
   
  Step 3: Please provide the following demographic information.
   
What is your gender? What is the year of your birth?


   
What is your race/ethnicity? What is your employment status?













 
 
   
In what industry do you work?   If other, please specify.
 
   
What is your highest level of education? Are you a manager/decision maker in
your job?


   
   
  Step 4: Although not required, the following information will help us match you to research project requirements.
   
What is your total household income before taxes?
 
Do you have children under 18 years of age living in your household?
1st Child's Year of Birth & Gender:   Male Female
2nd Child's Year of Birth & Gender   Male Female
3rd Child's Year of Birth & Gender   Male Female
4th Child's Year of Birth & Gender   Male Female
5th Child's Year of Birth & Gender   Male Female
6th Child's Year of Birth & Gender   Male Female
 
Do you have a dog?   Do you have a cat?
   
  Do you use tobacco in any form? Please check any applicable boxes below.
  Smoke cigarettes
Smoke cigars
Chew tobacco
Other
    Please specify
   
  Do you consume alcohol? Please check any applicable boxes below.
  Do you drink beer or wine?
Do you drink other alcoholic beverages?
   
  How often do you dine out?
 
   
  Please check any applicable boxes below.
  Do you purchase food from fast food restaurants?
  Do you frequently shop for organic foods?
  Do you exercise regularly?
  Do you diet?
   
  Do you subscribe to cable TV?
  Do you subscribe to satellite TV?
   
  Do you own a cellular phone?
  Who is your cellular phone service provider?
 








Please specify
   
  Are you a registered voter?
  What is your political affiliation?
 





Please specify
   
  How do you tend to lean politically?
 








   
  Do you visit casinos more than two times per year? (Check if yes.)
   
  Do you own an automobile?
 



  What model year?
 
  What make?
 

   
  Which, if any, of the following health conditions do you have? Please check any
applicable boxes below.
  Asthma
  Obesity
  Heart condition
  High blood pressure
  High cholesterol
  Arthritis
  Cancer
  Pulmonary Disease
  Allergies
  Diabetes
  Migraine headaches
  Acid reflux
  Insomnia
  Incontinence
  Acne
  Glaucoma
  Other Please specify
   
  Please check any applicable boxes below.
  Do you make purchases over the Internet?
  Do you bank or pay bills online?
  Do you use credit cards?
  Do you read the newspaper daily (print/online)?
  Do you read magazines regularly?
   
   
 
   
   
   
 
     
 
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