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:
1.
Are you?

Female Male
2.
What year were you born?

3.
What is your marital status?

Married Single, never married Divorced/separated Widowed
4.
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
5.
What is your current employment status?

Employed
Full-Time
Employed
Part-Time
Homemaker Retired/
Disabled
Student Not Employed
6.
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
7.
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
8.
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
9.
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.