Market Resource Associates

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Market Resource Associates Inc. will never sell, rent, or distribute your information to third parties. Your information will be used solely by Market Resouces Associates Inc. for focus group and research opportunities.

First name:
Last name:

Gender:

Cell Phone Number: ( ) -

Buisness Phone Number: ( ) -

Home Phone Number: ( ) -

E-mail:

Address:

City:

State:

Zip:

County:

Date of Birth:

Marital Status:

Political Affiliation:

Ethnic background:

Type of Residence:

Do you:
Own your Residence
-- If you own your residence, what is the approximate value of your home?
Rent your Residence

Education Level:

Hours worked per week (average):

Occupation:

Job Title:

Industry:

Annual Household Income:

Please indicate the age and gender of any children under 18 living in your household:

- Date of Birth: -- Gender:
- Date of Birth: -- Gender:
- Date of Birth: -- Gender:
- Date of Birth: -- Gender:
- Date of Birth: -- Gender:

Do you drink beer?
Yes -- No
- IF YES...
...Do you drink light beer or regular beer most often?

Please list your top 3 favorite beers
--
--
--

Cable TV Provider:

Internet Provider:

What are your top 3 favorite TV channels?
--
--
--

What are your top 3 favorite radio stations
--
--
--

What is the year and brand of the car you drive most often?
Year: -- Brand:

Do you own a cat?
Yes
No

Do you own a dog?
Yes
No

Which best describes you?
Never smoked
Current smoker
Former smoker

PLEASE MAKE SURE ALL QUESTIONS ABOVE ARE ANSWERED - YOUR FORM MAY NOT BE PROCESSED IF ALL QUESTIONS ARE NOT ANSWERED

By typing my name below, I authorize Market Resource Associates to call and/or e-mail me about focus group and research opportunities