Winn Winn Focus Group Registration Form
What is your first name? *
Your answer
What is your last name? *
Your answer
What is your gender? *
What is the best telephone number to reach you? *
Your answer
What city and state do you reside in? *
Your answer
What is your zip code? *
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Do you have any children? *
If you have children, what are their GENDERS and AGES? (Ex: M-5, F-10)
Your answer
Are you a United States Citizen? *
Are you registered to Vote? *
What is your date of birth? (Month/Date/Year) *
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YYYY
What is your ethnicity *
Are you employed...? *
If you are currently unemployed, are you...?
What is your occupation or former occupation? (If Student, list your major) *
Your answer
Who is your employer? (Required. Information shared is confidential) *
Your answer
What is the highest level of education you have completed? *
What is your marital status? *
Household Income *
What is your total household income (includes everyone in your home)?
Do you speak, read and write in English fluently?
What type of cell phone do you own? *
What is the make and model of your cell phone? *
(For Example: Iphone 4S or Samsung Galaxy 2)
Your answer
Who is your cell phone provider? *
(For Example: Sprint, Verizon, etc)
Your answer
Do you own a tablet? *
If yes, what type of tablet do you own?
Your answer
What banks do you bank with? *
Your answer
If you bank with more than one bank, which one is your primary? *
(Please type N/A if this does not apply to you)
Your answer
What types of accounts do you have with your primary bank? *
(Please type N/A if this does not apply to you)
Your answer
What type of credit cards do you own? *
Required
American Express owners, please indicate which type
Personal, Business, or Corporate - Green, Gold, Platinum, Delta, etc
Your answer
What is the make, model and year of the car you own?
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What is your e-mail address? *
Your answer
Do you accept text messages? *
What is the latest time we may call or text you? *
Your answer
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