Essential Information   First Name     Last Name     Address     City     State     Zip     Home or Work?   Choose One Home Work Both   Office Phone     Home Phone     Cell Phone     FAX     Email     Employment   Choose One Part Time Full Time Self Employed Unemployed Retired Homemaker           How many focus groups have you attended?   0 1 2 3 4 5 6 7 8 9 10+               Important Information - Work   Job Title     Level of Responsibility   Choose One Management Executive Department Head Director Supervisor Staff Other   Company     #Employees at Location     #Employees Companywide     Industry   Choose One None Advertising Agriculture Airline/Aerospace Apparel/Textile Architecture/Building Art/Photography/Journalism Automotive/Motor Vehicles/Parts Banking/Financial Biotechnology Broadcasting/Radio/TV/Media Building Materials Chemicals Construction Charitable/Not for Profit Computer Hardware Computer Software Consulting Consumer Products Credit/Loan/Collections Defense Education/College Electronics Employment/Recruiting Energy/Utilities/Gas/Electric Entertainment Environmental Food/Beverage/Tobacco Funeral/Cemetery Government/Civil Service Healthcare/Health Services Hospitality Hotel/Resort HVAC Import/Export Industrial Insurance Internet Landscaping Law Enforcement/Military Legal Leisure Library Science Managed Care Manufacturing Marketing Merchandising Mortgage Office Equipment Oil Refining/Petrol/Drilling Other Packaging Pharmaceutical Printing/Publishing Public Relations/Fundraising Real Estate/Property Management Restaurant Retail Recreation Sales Securities Security Semiconductor Social Services Telecommunications Training Transportation Travel Wireless   Occupation   Choose One None Accounting Administrative Business Development Communications Contract/Freelance Customer Service Engineering Executive Facilities Maintenance Finance Franchise Human Resources Information Technology Legal Nonprofit Other Owner Partner Production Purchasing Research Sales/Marketing Security Training               Optional Information - Technology   Computer 1   Choose One None PC Mac Other   Laptop?   Choose One Yes No   OS Version     Printer Brand 1     Computer 2   Choose One None PC Mac Other   Laptop?   Yes Choose One No   OS Version     Printer Brand 2     Peripherals   CD Drive - Read only   External Hard Drive CD Drive - Rewritable   Scanner Zip Drive   Combination copier/scanner/fax   Savvy Level   Beginner Choose One Proficient Expert Geek   Can Do   Emails   Financial Software Word Processing   Downloads Spreadsheets   Games   ISP     URL     Pager Brand     Cell Phone Brand                 Optional Information - Demographic   Gender   Choose One Male Female   Birth Year   Choose One 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900   Education   Choose One High School Trade School Some College 4 Year Degree Postgraduate   Ethnicity   Choose One African American Asian Caucasian Hispanic Middle Eastern Native American Other   Marital Status   Choose One Single Engaged Married Divorced Widowed   Number in Household     Number of Children                 Optional Information - Housing   Household Income   Choose One Under $20k $20k-29K $30-39k $40-49K $50-59k $60-69k $70-79k $80-89k $90-99k $100-250k $250k plus   Housing Type   Choose One Apartment Condominium Duplex House   Own or Rent   Choose One Own Rent               Optional Information - Political   Party Affiliation   Choose One Democrat Republican Green Labor Libertarian Reform Socialist Other   Registered to Vote   Yes Choose One No               Optional Information - Consumer   Car 1 Make/Model     Car 2 Make/Model     Smoking   Cigarettes   Pipe Cigars   Other   Drinking   Beer       Wine       Mixed Drinks         Eating   Choose One Omnivore Vegetarian Vegan               Optional Information - Personal       Note:  Holding down the Control key (PC) or Command key (Mac) when making selections will allow you to choose more than one category.   Sports/Fitness   Choose All That Apply Aerobics Baseball Basketball Climbing Cycling Dancing Football Golf Hiking Martial Arts Running Sailing Soccer Surfing Tennis Weight Training Xtreme Sports Yoga Other   Hobbies   Choose All That Apply Antiques Brewing Collecting Cooking Crafts Fishing Gaming Gardening Models Photography Quilting Reading Sewing Winemaking Woodworking Writing Other   Interests   Choose All That Apply Art Camping Cars Celebrities Children Cigars Computers Decorating Health Education Family Fitness Food Global Issues History Home Furnishings Internet International Affairs Investing Memorabilia Movies Music Nutrition Parenting Pets Politics Religion/Spirituality Shopping Social Trends Television Travel Volunteering Wine Other               Optional Information - Fill in the Blanks   For fun I like to:     For relaxation I like to:     My dream vacation is:     In a group I am:     Five words that describe me are: