First Name:

 Last Name:

Address:

City:

State:

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Zip:

County:

Home Phone (be sure to include area code):

Work Phone (be sure to include area code):

Ext:

Cellphone (be sure to include area code):

Brand:

LG Motorola Nokia Sony/Ericsson Sanyo Samsung Other

Carrier:

AT&T Wireless Cingular Nextel Sprint T-Mobile Other

Fax (be sure to include area code):

E-mail:

Date of Birth (Please use mm/dd/yyyy format):

Ethnicity:

Caucasian African American Hispanic Asian, Pacific Islander American Indian, Eskimo Other

Gender:

Male Female

Marital Status:

Married Single Divorced/Separated Widowed

Party Affiliation:

Republican Democrat Independent Other

Education Level:

Some grade school Some High School High School Grad./GED Some College College Grad. Advanced Degree

Annual (Yearly) Household Income:

Less than $25,000 $25-$35,000 $35-$45,000 $45-$55,000 $55-$65,000 $65-$75,000 $75-$85,000 Over $100,000

Are you fluent in Spanish?

No, not fluent Yes, fluent

The year/make/model of the car you yourself drive most often:

Year:

1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Make:

ACURA ALFA-ROMEO AM/AMC ASTON MARTIN AUDI BENTLEY BMW BUICK CADILLAC CHEVROLET CHRYSLER DAEWOO DAIHATSU DODGE EAGLE FERRARI FORD GEO GMC HONDA HUMMER HYUNDIA INFINITI ISUZU JAGUAR JEEP KIA LAMBORGHINI LAND ROVER LEXUS LINCOLN LOTUS MAZDA MERCEDES-BENZ MERCUR MERCURY MINI MITSUBISHI NISSAN OLDSMOBILE PEUGEOT PLYMOUTH PONTIAC PORSCHE ROLLS-ROYCE SAAB SATURN SCION SUBARU SUZUKI TOYOTA VOLKSWAGON VOLVO OTHER

Model/type of vehicle:

4-door sedan 2-door sedan Pickup truck SUV Station wagon Minivan Full-size van Other

Employment Status:

Full time Full time: exec; manager Part time Unemployed; laid off Retired Homemaker Student Other

Occupation:

Employee Manager Vice-President President; other executive Secretarial Self-employed Accounting/bookeeping Other

What is your Job Title?

Please indicate the type of industry which best describes the type of business you work in:

Agriculture; farming Computers; high-tech Education Financial services Government; military Healthcare Manufacturing Mining; oil & gas; utilities Other private sector Real estate Restaurant Retail business Tourism Transportation Other

County in which you work:

How often per year do you travel for business by air domestically?

Never Once a year or less A few times per year Less than once a month Once a month More than once a month Once per week More than once per week Other

Internationally?

Never Once a year or less A few times per year Less than once a month Once a month More than once a month Once per week More than once per week Other

If you are self-employed, is there at least one full-time employee besides yourself?

Yes No

(If you have a spouse)

Would your spouse like to attend focus groups?

Yes No

(If you have a child(ren) under the age of 18 living in your household and you are the legal guardian or parent of the child(ren)
 

Child 1 Gender :

Male Female

Date of Birth:

Child 2 Gender :

Male Female

 Date of Birth:

Child 3 Gender :

Male Female

 Date of Birth:

 Child 4 Gender :

Male Female

 Date of Birth:

 Child 5 Gender :

Male Female

 Date of Birth:

 Child 6 Gender :

Male Female

 Date of Birth:

Would your child(ren) like to attend a focus group?

Yes No

Do you own or rent your primary residence (where you live more than 50% of the time)?

Own residence Rent residence Lease residence Other

 What type of dwelling place is that?

Single family home Apartment Condo Mobile home/trailer Farm Other

 What types of Pets do you have in your home:
(Press the <ctrl> key while clicking to make multiple selections)

Cat Dog Bird Fish Reptiles Small animals (rabbit, hamster, etc.) Other

Home Desktop Computer:

PC Apple Macintosh None Other

 Home Laptop Computer:

PC Apple Macintosh None Other

What is your favorite?

AM Radio Station:

KANI 1500 AM KBME 790 AM KCOH 1430 AM KEYH 850 AM KGOL 1180 AM KIKK 650 AM KILE 1560 AM KILT 610 AM KJOJ 880 AM KKHT 1070 AM KLAT 1010 AM KLVL 1480 AM KMIC 1590 AM KNUZ 1090 AM KPRC 950 AM KQUE 1230 AM KRTX 980 AM KSEV 700 AM KTEK 1110 AM KTRH 740 AM KWWJ 1360 AM KXYZ 1320 AM KYND 1520 AM KYOK 1140 AM KYST 920 AM Others

FM Radio Station:

KACC 89.7 FM KAYD 97.5 FM KBXX 97.9 FM KHCB 105.7 FM KHMX 96.5 FM KHPT 106.9 FM KIKK 95.7 FM KILT 100.3 FM KJIC 88.1 FM KJOJ 103.3 FM KKBQ 92.9 FM KKRW 93.7 FM KKTL 97.1 FM KLDE 107.5 FM KLOL 101.1 FM KLTN 102.9 FM KMJQ 102.1 FM KODA 99.7 FM KOVE 93.3 FM KPFT 90.1 FM KPVU 91.3 FM KQQK 106.5 FM KRBE 104.1 FM KRTS 92.1 FM KRTX 100.7 FM KSBJ 89.3 FM KTBZ 94.5 FM KTJM 98.5 FM KTRU 91.7 FM KTSU 90.9 FM KUHF 88.7 FM KXTJ 107.9 FM Others

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