Survey Panel - Fairfield Research, Inc.

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Media Research of the Future...Today

Join Our Consumer Survey Panel

Your opinions are of tremendous value to us and to our survey clients. We are inviting you and your household to become part of our exclusive Consumer Research Panel. As a panel member, you, or other family members, will be asked to share your opinions several times a year through surveys and possible panel discussions. Each time you complete a survey you have a chance to win prizes in our monthly drawings.

For filling out this profile and joining the panel you will be entered into a drawing for the following prizes:

Gift certificates from Best Buy, The Gap, Eddie Bauer, and Land’s End

Computer games

Personal Digital Assistants / Handheld Computers

We look forward to hearing from you, and we thank you in advance for your participation.

General Information

First Name:
Last Name:
Street Address:
City/State/Postal Code:
Country:
Voice Phone:
E-Mail Address:

Are you?

Female	Male

What year were you born?

What is your marital status?

Married	Single, never married	Divorced/separated	Widowed

Please indicate the highest level of education that you have completed.

Have not finished High School	High School Graduate	Attended College/ Post HS Training	College Graduate	Post Graduate Work/Degree

What is your current employment status?

Employed Full-Time	Employed Part-Time	Homemaker	Retired/ Disabled	Student	Not Employed

Please indicate the ages of children in your household.

under 2 years old	2-5 years old	6-12 years old	13-18 years old	No children under 18 living at home

What is your total combined annual income, before taxes, of all household members including yourself?

Under $30,000	$30,000- $49,999	$50,000- $74,999	$75,000- $99,999	$100,000- $149,999	$150,000- $199,999	$200,000+	Prefer not to answer

Do you or your family own or rent your primary residence?

Own Home	Own condo/co-op /town house	Rent House	Rent apt/condo/ co-op/town house	Other

Do you have access to the Internet .....?

At Home	At Work	Both

10.

How often do you access the Internet?

Daily	Weekly	Monthly	Less than once a month

11. (a)

How many telephone lines (land lines) do you have coming into your home? (usually each separate telephone number has its own line)

None	1	2-3	4-5	6+

11. (b)

How many cell phones do you have in your household?

None	1	2	3	4	5+

11. (c)

Do you have a cell phone that has any of the following? Check all that apply.

	Text message
	Takes photos
	Plays ring tones
	Internet access
	Sends & receives email
	Plays games
	None of the above

12.

Do you have an office in your home where someone ...........?

	Runs a business out of the home
	Brings work home to do
	No office in the home

13. (a)

Which if any of the following products does your family own?

13. (b)

Which have you purchased in the last year?

13. (c)

Which are you likely to purchase within the next year?

Video Game System	Currently Own	Purchased in Last Year	Will Purchase in Next Year
Nintendo Wii
Nintendo DS/DS Lite
Nintendo GameCube
Nintendo Gameboy Advance
Microsoft XBox
Microsoft XBox 360
Sony PlayStation 2
Sony PlayStation 3
Sony PSP
Other	Currently Own	Purchased in Last Year	Will Purchase in Next Year
PDA/Handheld Computer
Satellite Dish
Home Theater System
Big Screen HD TV - 32"+
DVD Movie Player
Home PC
Digital Camera
Digital Camcorder
iPod/MP3 Player

14. (a)

Has your household purchased any of the following major appliances in the last year?

14. (b)

Will your household likely purchase any of the following in the next year?

	Purchased in Last Year	Will Purchase in Next Year
Refrigerator
Freezer
Washer
Dryer
Microwave
Stove or range
Dishwasher

15.

How many trips do you take in a typical year? (trips with at least one night stayover, including business and personal)

Domestic	Foreign

16. (a)

Do you or does anyone in your household read or page through any of the following magazines?

16. (b)

Does that person subscribe to the publication, buy it on the newsstand, read someone else's copy or read it on the Internet?

	Read or page through	Subscribe	Read someone else's copy	Buy it on the newsstand	Read only on the Internet
All You
American Homestyle & Gardening
Better Homes & Gardens
Bon Appetit
Business Week
Child
Conde Nast Traveler
Cosmopolitan
Country Living
Esquire
Family Circle
Field & Stream
Fitness
Fortune
Garden Design
	Read or page through	Subscribe	Read someone else's copy	Buy it on the newsstand	Read only on the Internet
Glamour
Golf
Good Housekeeping
Gourmet
GQ
Harper's Bazaar
House Beautiful
House & Garden
Ladies Home Journal
Lucky
Marie Claire
Motor Boating
O, The Oprah Magazine
	Read or page through	Subscribe	Read someone else's copy	Buy it on the newsstand	Read only on the Internet
Outdoor Life
Parents
People
People en Español
Popular Mechanics
Popular Science
Quick & Simple
Reader's Digest
Redbook
Salt Water Sportsman
Saveur
Self
Seventeen
Ski
Skiing
	Read or page through	Subscribe	Read someone else's copy	Buy it on the newsstand	Read only on the Internet
The Sporting News
Sports Illustrated
Sports Illustrated for Kids
Teen
Town and Country
Time Magazine
Veranda
Victoria
Vogue
Woman's Day
Yachting
YM

17. (a)

Which type of vehicle(s) do you, or does anyone in your household, own or lease?

17. (b)

Have you, or has anyone in your household, purchased or leased any of the following types of new vehicles in the past two years?

	Currently own or lease	Purchase or leased in last two years
Luxury Car
Basic Large Car
Sporty Car
Midsize Car
Compact Car
Compact 4x2/4x4 Pickup
Full size 4x2/4x4 Pickup
Sport Utility Vehicle
Van

No purchase necessary

Void where prohibited

Likelihood of being drawn as a winner will depend on the number of entries

This drawing is not open to employees of Fairfield Research, Inc.