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If you are interested in joining our focus group database, please fill out the following form and your information will be added to our records. We will contact you when we have a focus group for which you might qualify. (* optional)

First Name
M.I.*
Last Name
Mailing Address
Address Line 1
Address Line 2*
City
State / ZIP		,
Home Address (if different)*
Address Line 1
Address Line 2
City
State / ZIP		,
Contact Information
Home Phone Number		- -
Cell/Alternate Phone No.		- -
Your Email Address
Work Information
Type of Occupation
Professional/Executive/Owner White Collar/Administrative/Clerical Blue Collar/Service/Manufacturing Stay at Home/Do not work Unemployed Student Retired Other, Specify:
Your Occupation or Industry (i.e. job title, type of work) (if applicable)*
Are you an employee of the local, state, or federal government?
Yes, local government Yes, state government Yes, federal government No
Work Schedule (if applicable)*		Part Time Full Time
Employer Name
Address Line 1
Address Line 2*
City
State / ZIP		,
Work Phone		- -
Work Email Address
Best phone no. at which to reach you during the day:		Work Cell/Alt. Home
Spouse’s or Partner’s Type of Occupation (if applicable)*
Professional/Executive/Owner White Collar/Administrative/Clerical Blue Collar/Service/Manufacturing Stay at Home/Do not work Unemployed Student Retired Other, Specify:
Spouse's Occupation or Industry (i.e. job title, type of work)*
Demographic Information
Gender		Male Female
Year of Birth
Racial or ethnic background
White/Caucasian Black/African-American Hispanic/Latino Asian/Pacific Islander Middle Eastern Native American Other (please specify)
Marital Status
Single Single in relationship/engaged Married Divorced Separated Widowed
Religion
Protestant Catholic Mormon Jewish Muslim Agnostic or Atheist Other (please specify):
Highest Level of Education Completed
Less than High School High School Graduate Post High School Vocational or Technical School Some College Two Year College Graduate Four Year College Graduate Post Graduate Degree
Estimated Annual Household Income Before Taxes
Below $25,000 $25,000 TO $29,999 $30,000 TO $39,999 $40,000 TO $49,999 $50,000 TO $59,999 $60,000 TO $69,999 $70,000 TO $79,999 $80,000 TO $89,999 $90,000 or Higher
Do you rent or own your home?		Own Rent
Do you have access to the Internet at home?		Yes No
Do you have children?		Yes No If yes, ages:
Political Affiliation
Democrat Republican Independent Other (please specify)
Have you participated in any focus groups in the past?		Yes No
If yes, how many?
What were the topic(s)?
Date that you last participated in a focus group:
Thank you for completing this focus group application. We will be in touch the next time a focus group opportunity becomes available for which you might qualify.
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