So we can match you to our studies, please fill out this form as completely as possible. We respect your privacy. Information that you provide in this form is kept strictly confidential, and under no circumstances will it be sold to any other organization. Read our privacy statement.


Contact information

Your name:  
*first name(s) *last name/surname

Address:
 

Address line 2:
 
   

City:

*State:

*Zip code:
County or Parish:
(not "Country")
 



*Please provide your daytime phone number AND evening phone number
  so that we may contact you if you are a candidate for one of our panels. We also will use your email address if you wish.

Daytime phone:
 
( ) - ext

Evening phone:
 
( ) - ext

Best time to call:
 

Time Zone:
 

Email address:
 





Tell us about yourself!

Date of Birth:



What is your gender?  female male

Which of these categories best describes your family status?

Including yourself, how many persons are in your household?  

Which category best represents your annual household income?  

Do you own or rent your residence? Own Rent

Do you own a second home? Yes No

What is your occupation? 

If you selected 'other', please specify: 
If you anwered "Unemployed", in what industry? 
If you anwered "Retired", from what industry? 

Which of these categories best describes your education? 

Are you registered to vote? Yes No

How would you describe your ethnicity?
Asian
African American
Caribbean
Caucasian
Hispanic/Spanish/Latino
Native North American/Aboriginal
Other
Prefer not to answer




Please tell us in which of the following activities you actively participate?
(Please check all that apply.)
Skiing Walking
Snowboarding Hiking
Swimming Running
Fishing Bicycling (road)
Team sports Mountain biking
Kayaking/canoeing Rock climbing
Racquet sports    
Other:




Do you own a pet?
(Please check all that apply.)
Dog Cat
Horse Other:




What percentage of your grocery shopping do you do at each of the following types of markets?  (Record a percentage (%) for each type of store.)
Discount grocers or Club membership stores  %
Conventional grocery or supermarket  %
Natural food stores  %
Other (specify)  %  specify: 




For households with children living at home: In which years were your children born?
(Enter the full year e.g. 1988)
#1  #2  #3  #4  #5  #6 




Which, if any, radio stations do you listen to in an average week?
#1 
#2 
#3 
#4 
#5 
#6 




Year, make, model and type of most recent vehicles owned/leased
 
Year
e.g. 1988
Make
Model
Type
#1 

#2 

#3 





Other Hobbies & Interests/Notes?


And finally . . . how did you hear about the Boulder Focus Center consumer panel?
friend/relative/colleague (word of mouth) 
flyer 
postcard or mailing 
email, from: 
advertisement in newspaper or magazine, which one: 
internet site, which one: 
recruiter call
other, specify: 



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Phone: 303-449-6558 ext.2101  ·  Fax: 303-449-6587  ·  Email: info@boulderfocuscenter.com
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