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:
Date of Birth: (MM/DD/YYYY)
Home Phone:
Work Phone: numbers only 10 digits... must include area
Cell phone/pager:
Home Address
City
Home Zip Code:
Your Gender
Ethnic Background?
What is your Nationality?
What is your Marital Status?
Do you suffer from any medical ailments, Check all that apply?
Adult Macular Degeneration (A.M.D)Alzheimers DiseaseArthritisAsthma
Attention Deficit Hyperactivity Disorder (A.D.H.D)Chronic Obstructive Pulmonary Disease (C.O.P.D)Crohns Disease
DepressionDiabetesHeart DiseaseHigh Blood Pressure
High CholesterolIrritable Bowel Syndrome (I.B.S)Multiple SclerosisObesity
Parkinsons DiseasePeripheral Artery Disease (P.A.D)Restless Leg Syndrom (R.L.S)Sleep Disorder (Insomnia)
If you have Cancer, Please specify Cancer:
If you have Other, Please specify Other:
Family Information:
First Child
Date of Birth  
Second Child Date of Birth
Third Child Date of Birth
Fourth Child Date of Birth
Fifth Child
Date of Birth
Sixth Child Date of Birth
Occupation?
Industry?
Job Title?
Travel for Business?
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.) 







Which is your highest level of education completed?




Do you own a computer?
If yes, What Brand(s)? 
Are you connected to the internet? 
If Yes, Internet Provider (ISP)?
Vehicles
Car 1:
Make: Model: Year:
Car 2:
Make: Model: Year:
Car 3:
Make: Model: Year:
Car 4:
Make: Model: Year:
Do you own a watercraft?
If yes, What type?
Do you smoke?
If yes, What Brand? 
Do you own a pet?
If yes, What type? 
Do you own a cell phone?
If yes, What Brand?
Cellular Service Provider?
Political Affiliation?
What type of residence do you live in?
  Ownership?
Which, if any, do you drink?
If you drink BEER, what brand most often?
If you drink WINE, what brand most often?
If you drink LIQUOR, what brand most often? 
Which of the following do you own?









What type of TV do you have in your home?
What type of TV connection do you have at home?
What type of internet service do you have?
Have you ever purchased a product on line?
Which of the following wireless devices do you use to connect to the internet?
 Other:
Which banking institution do you use?
Which of the following credit cards do you use?
 Other:
How did you hear about us?