New England Interviewing Sign-up Form

Consumer Survey Screener

We are a local research company, and we pay people to do surveys in the future. For example, we do
clothing and toy studies, food tasting, and political groups. Again, you will be paid for your time and opinions in these studies.
I assure you this information will never be shared or sold. To best fit you into future studies please answer the following questions.

Respondents from New Hampshire, Massachusetts, Maine and Vermont only please.

Required Fields = *
Gender:
 *
Marital Status:
 *
Full Name:
 *
Race:
 *
DOB: ( MM-DD-YYYY )
 *


Home Number:
 *
Cell Number:
Work Number:
 Extension:


Address: (NH, MA, ME, VT only)
 *
City, State, ZIP:
 *
County:
 *


E-mail:
 *
Occupation (If retired, former occupation):
 *
Education: Highest level completed to date
 *
Registered to vote?:
 yes no
Party:
Did you vote in the Primary?:
 yes no
Combined Income:


Gender:
Spouse's Full Name:
Race:
DOB: ( MM-DD-YYYY )
 *


Cell Number:
Work Number:
 Extension:


E-mail:
Occupation (If retired, former occupation):
Education: Highest level completed to date
Registered to vote?:
 yes no
Party:
Did you vote in the Primary?:
 yes no


How many other people live in your household?:

Name: DOB: (MM-DD-YYYY) Male / Female:M F
Name: DOB: (MM-DD-YYYY) Male / Female:M F
Name: DOB: (MM-DD-YYYY) Male / Female:M F
Name: DOB: (MM-DD-YYYY) Male / Female:M F
Name: DOB: (MM-DD-YYYY) Male / Female:M F
Name: DOB: (MM-DD-YYYY) Male / Female:M F


What radio station do you most listen to?:

Do you have pets? Please select all that apply:

Pet Number 1:
Pet Number 2:
Pet Number 3:
Pet Number 4: