•  Please provide the following information so that we may contact you. Please be assured that this information will be kept strictly within the AGE database and will be used for market research studies only.

First name:


Last name:


Cell number:


Home phone number:


Work phone number:


Ethnic Origin:


E-mail address:


Province/State:


Country:


•  Do we have your permission to contact you to participate in one of these market research studies in the near future?

 Yes     No

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

•  Age



•  May we have your exact date of birth?

     

•  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

•  Accommodation



•  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:


•  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

•  Do you have pets?

  None
  Cat
  Dog
  Other

•  Have you ever suffered from any of the following?

  Arthritis
  Asthma
  Cancer (breast)
  Cancer (prostate)
  Cancer (other)
  Crohns
  Diabetes
  ED
  Heart Disease
  High Cholesterol
  IBD
  Psoriasis/Eczema
  Other

•  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




THANK YOU VERY MUCH!