In order to classify potential candidates for future research, we have a few questions for you:

• As we speak to people in different age groups, what is your exact age at the present time?
  
• May we have your exact date of birth?
  Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year
• Are you:
  Male Female
• Which of the following best describes the current makeup of your household?
  Single Adult
  Couple
  Adults only (2 or more)
  Family with any children under 18
  Family with only children 19 or older
• Which of the following best describes your marital status?
  Married
  Common-law / living with a partner
  Single (never married)
  Separated or divorced
  Widowed
• Which of the following best describes your occupation? Are you currently...?
  Full time employed outside the home
  Part time employed outside the home
  Self-employed
  A full time student
  Homemaker / at home caring for children
  Unemployed / looking for work
• If you answered that you are employed, what is your occupation?
  Position / Title / Profession:
  
  Name of Company:
  
  Type of Company / Industry:
  
• If Married / Common-law, what is your spouse’s occupation?
  Position / Title / Profession:
  
  Name of Company:
  
  Type of Company / Industry:
  
• If you are a student, are you currently enrolled in...
  Elementary school
  Middle or junior high school
  High school
  College or trade school -- undergraduate degree or diploma program
  University -- undergraduate degree progam
  University -- post-graduate degree program
  University -- professional program
• Which of the following best describes your total household income before taxes?
  $0 up to $20,000
  $20,000 to $39,999
  $40,000 to $59,999
  $60,000 to $79,999
  $80,000 to $99,999
  $100,000 to $149,999
  $150,000 to $199,999
  $200,000 or more
• What is the highest level of education you have personally completed?
  Some High School
  Completed High School
  Some Technical School, College or University
  Completed Technical School, College or University
  Some post-graduate or professional education
  Post-graduate degree(s) and / or professional degree
• At the present time, do you or does anyone in your household own or lease any vehicles? If so, please record the make model and year of any vehicles in your household below.
  Vehicle 1
  Make:
  
  Model:
  
  Year:
  
  Vehicle 2
  Make:
  
  Model:
  
  Year:
  
  Vehicle 3
  Make:
  
  Model:
  
  Year:
  
  Vehicle 4
  Make:
  
  Model:
  
  Year:
  
• Do you personally have and use any of the following?
  A computer at home
  A computer at work
  Dial-up Internet access
  High speed Internet access
  A cell phone
  A pager
• Do you use any of the following for your regular banking transactions?
  ATM / Banking machine
  On-line / Internet banking
  Automated telephone system banking
• Are you interested in participating in any of the following types of market research studies in the future?
  Focus group discussions
  Individual interviews or paired interviews
  On-line focus groups
  On-line interviews
  Telephone interviews
• Do we have your permission to contact you to participate in one of these market research studies in the near future?
  Yes
  No
• Please provide the following information so that we may contact you. Please be assured that this information will be kept strictly within the Consumer Vision database and will be used for market research studies only.
  First name:
  
  Last name:
  
  Phone number:
  
  E-mail address:
  

THANK YOU VERY MUCH!

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