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ADLER-WEINER RESEARCH ORANGE COUNTY

Consumer's/Professional's Questionnaire

Dear Consumer/Professional:

We at Adler-Weiner Research have been asked to speak with consumers and professionals in depth about the products or services that you are using or those products and services that are still under development. Your opinions are vital to this process and will help us understand how to serve you best. Please take the time to fill out this brief questionnaire; it is for our demographic records ONLY.

Please refer to our Zip Codes page to verify you live within the coverage area.
We ask you to note, that currently, Adler Weiner research does NOT do any online studies, so please sign up to participate only if You are able join us at our facility.

Thank you.

INDIVIDUALS WHO HAVE AN EXISTING PROFILE CANNOT UPDATE THEIR PROFILE ONLINE.

YOU MUST CALL 310-440-3199 TO UPDATE.

GENERAL INFORMATION

* - denotes required fields

*First Name:

*Last Name:

You must include at least one phone number.

*Home # :

Work # :

Cell # :

Pager # :

Fax # :

*E-Mail:

*Confirmation E-Mail:

*Address:

Apt./Suite:

*City:

*State:

*Zip:

*Ethnicity:

*Date of Birth:

*Gender:

*Marital Status:

*Education:

Hair Color:

*Personal Income:

*Household Income:

*Housing Type:

CHILDREN INFORMATION

Do you have children under the age of 18 living in your home?

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Name:

Gender:

DOB:

Name:

Gender:

DOB:

Name:

Gender:

DOB:

Name:

Gender:

DOB:

Name:

Gender:

DOB:

Name:

Gender:

DOB:

EMPLOYMENT
*Employment Status:
*Title:
*Occupation:
*Industry:
*Company:
*# Local Employees:
*# Total Employees::
*Annual Sales:
*Number of domestic work trips per year:
*Number of international work trips per year:

COMPUTERS/INTERNET

*Brand of your computer at home:
*On-Line Provider:
*Internet Connection Speed:
*Gaming Systems:
*Game Types:

Complete Information for Car YOU Drive Most Often:
Make:	Model:	Class:	Year:
If Additional Car in Household (yours, spouse's, child's, other) Complete Fields Below:
Make:	Model:	Class:	Year:

CREDIT CARD INFORMATION
Complete Fields Below for Each Card Owned:
Credit Card 1:
Credit Card 2:
Credit Card 3:
Credit Card 4:

TELEPHONE INFORMATION
Local Telephone Carrier?
Long Distance Carrier?
Cell Phone Provider:

MISCELLANEOUS INFORMATION

TV, Cable, Satellite Provider:
What is your Political Party?
Do You Drink Any of the Following Beverages?:	Select all that apply ...
	Beer	Wine	Spirits/Mixed Drinks
	Cordials/After Dinner		None

CIGARETTES
Do You Smoke Cigarettes?	Yes No
Primary Brand
Alternate Brand
Flavor
Length
Type

PETS
Do You Have Any Pets 1:
Do You Have Any Pets 2:
Do You Have Any Pets 3:
Do You Have Any Pets 4:
Do You Have Any Pets 5:

MEDICAL CONDITIONS

Medical Conditions 1:
Medical Conditions 2:
Medical Conditions 3:
Medical Conditions 4:
Medical Conditions 5:
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