Please fill out the registration form below. Be sure to complete as much information as possible.
    This gives you better chances of getting into a group. All information provided is strictly confidential.
*Required Information
 
*First Name:
*Last Name:
*Street Address:
Address (cont.)
*City:
*State/Province:
*Zip/Postal Code:
 *County:
*Date of Birth: (MM/DD/YY)
*Gender:
*Martial Status: 
*Ethnicity:
*Are you fluent in Spanish?
*E-mail:
*Home Phone:
*Work Phone:   Ext:     
*Cell phone:
*Brand:
*Cell Phone Carrier:
 
*Education:
*Employment Status:
*Occupation:
*What is your Job Title?
*Annual (Yearly) Household Income:
*Employer:
*Employer’s Industry:
*Company's Size:
*County in which you work:
*If Physician: Specialty:
*If MIS/IT: Are you?
*If you are self-employed, is there at least on full-time employee besides yourself?  
*How often per year do you travel for business by air domestically?  
*Internationally?  
 

(If you have a child(ren) under the age of 18 living in your household and you are the legal guardian or parent of the child(ren); (Please use mm/dd/yy format for the Date of Birth (D.O.B))

Child 1 Gender :
     

  D.O.B
 

would this child like to participate in focus groups:
Yes No

Child 2 Gender :
     

  D.O.B
 

would this child like to participate in focus groups:
Yes No

Child 3 Gender :
     

  D.O.B
 

would this child like to participate in focus groups:
Yes No

Child 4 Gender :
     

  D.O.B
 

would this child like to participate in focus groups:
Yes No

 
Please list your primary financial institution:
Please list your secondary financial institution:

Do you have a...

Mutual Fund:
Certificate of Deposit (CD):
Company sponsored 401K, IRA:
American Express:
Discover:
MasterCard:
Visa:
If you have a credit card that is affiliated with an airline, approximately, how many miles do you have?
Magazines that you read on a monthly basis:
(Select all that apply - Control<Ctrl>-click to make multiple selections - Scroll down to view the entire list)
 
The year/make/model of the car you yourself drive most often: Year:  

Make: 

Model:
Do you own or rent your residence?
Dwelling type:
Do you have Cable or Satellite?
Who is your Cable/Satellite Provider?
Home Desktop Computer:
Home Laptop Computer:
Internet Provider:
Internet Connection:
How do you feel about about Banking on-line:
How do you feel about about Trading on-line
How do you feel about about shopping on-line
 

What is your favorite?

AM Radio Station:
FM Radio Station:
Cigar:
Cigarette:
Beer:
Spirit/Liquor:
Wine:
Have you been diagnosed with any of the following:
(Select all that apply - Control<Ctrl>-click to make multiple selections - Scroll down to view the entire list)
Prescriptions Taken:
(Please separate each medicine with a comma)
 

Do you own and personally use on a regular basis…

MP3 Player:
DVR/Tivo:
HDTV:
Plasma/LCD:
Digital Camera:
DVD Player:
DVD Recorder:
Handheld Video Games:
Electronic Organizer/Palm Pilot:
Game Consoles:
(Select all that apply - Control<Ctrl>-click to make multiple selections - Scroll down to view the entire list)
 
*Best time to call:  
Availability to go on panels:
(Check all that apply)
Weekdays
Weeknights
Weekends
Have you ever participated in a focus group discussion? Yes
No
If yes, when was the last time you participated?
*How did you learn about us?
 

Would you like to be placed on our mailing list to receive emails about upcoming focus groups?            

Please click "submit" once to prevent duplicate registration forms

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Having trouble with the form please email us at help@winnwinn.com