3121 Michelson Dr., Suite 100, Irvine, CA 92612
Tel: (949) 870-4200, Fax: (949) 870-4219, Email: info@awr-oc.com

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ADLER-WEINER RESEARCH ORANGE COUNTY

Professional's Questionnaire

Dear 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 TO JOIN US AT OUR FACILITY.

THANK YOU !

GENERAL INFORMATION

*First Name:

*Last Name:

*Home # :

Work # :

Cell # :

Pager # :

Fax # :

*E-Mail:

*Confirmation E-Mail:

*Address:

Apt./Suite:

*City:

*State:

*Zip:

Ethnicity:

*Date of Birth:

Gender:

EMPLOYMENT
Employment Status:
Title:
Occupation:
Industry:
Company:
# Local Employees:
# Total Employees::
Annual Sales:

Do You Travel Domestically For Work?	Yes No	# of trips per year
Do You Travel Internationally For Work?	Yes No	# of trips per year

COMPUTERS/INTERNET

Do You Use a PC at home?	Yes No
Do You Use a Mac at home?	Yes No
Do You Use a PC at work?	Yes No
Do You Use a Mac at work?	Yes No

Brand of your computer at home:

On-Line Provider:
Internet Connection Speed:

CARS DRIVEN - please indicate most recent 2 automobiles.
Make:	Model:	Class:	Year:
Make:	Model:	Class:	Year: