Discussion Panel Information Questionnaire


WAC of South Florida, a Florida marketing research company, is looking for consumers like you to participate in focus groups. Registered respondents attend focus groups, provide their opinions on various topics, and receive cash incentives for their time. If you are interested in joining our database, please fill out this form. Your information is submitted to us over secure website and uploaded directly into our database. Your information will never be sold or used for any purpose except as a guide for our focus group screening purposes. This is an opportunity for you to attend focus group discussions & receive cash for your opinion. There will never be an attempt to sell you anything.

First Name:
Last Name:
Email Address:
Date of Birth: (MM/DD/YYYY)
Phone Number:
Cell Number:
Home Address
City
Zip Code:
Your Gender
Ethnic Background?
What is your Nationality?
What is your Marital Status?
Family Information:
Child 1
Date of Birth  
Child 2 Date of Birth
Child 3 Date of Birth
Child 4 Date of Birth
Child 5
Date of Birth
Which is your highest level of education completed?




Current Occupation?
Industry?
Company Name?
Vehicles
Vehicle 1: Make: Model:

Vehicle 2: Make: Model:
Are you Registered to Vote?
Political Party Affiliation?
Which of the following best describes the total combined income before taxes of all members of your household for last year.  (READ LIST)
(Please include all income for yourself and all persons living in your household from all sources. e.g. wages, bonuses, profits, dividends, rental income, interest, etc.) 







Do you suffer from any medical ailments, Check all that apply?
Alzheimers DiseaseArthritis
AsthmaAtrial Fibrillation
AutismBiPolar
Chronic Obstructive Pulmonary Disease (C.O.P.D)
Crohns DiseaseDiabetes Type 1
Diabetes Type 2Epilepsy
Heart DiseaseHemophilia
Hepatitis CHIV/AIDS
LupusMultiple Sclerosis
Parkinsons Disease
If you have Cancer, Please specify Cancer:
If you have Other, Please specify Other:
If you are currently a caregiver for anyone, Select the ailments that patient suffer from:
Alzheimers DiseaseArthritis
AsthmaAtrial Fibrillation
AutismBiPolar
Chronic Obstructive Pulmonary Disease (C.O.P.D)
Crohns DiseaseDiabetes Type 1
Diabetes Type 2Epilepsy
Heart DiseaseHemophilia
Hepatitis CHIV/AIDS
LupusMultiple Sclerosis
Parkinsons Disease
If patient has Cancer, Please specify Cancer:
If patient has Other, Please specify Other: