Accurate Data Marketing, Inc.



Join Our Database!

If you are interested in participating in our surveys and focus groups, please fill in the following form (required information MUST be filled out in order to be considered). We keep this information in our database for our use only and you will be contacted if your qualifications match those requested for a particular project. You will be under no obligation to participate. Those attending focus groups at any of our locations are compensated for their time. If you know of others who are interested and would like their opinions heard, please have them complete a form as well.

* Required Field
Referred By:
*Sex:
Male Female
*Last Name:
*First Name:
*Address:
*City:
*State: *Zip Code:
*Home Phone:
Cell Phone:
E-mail:
*Occupation:
*Industry:
If Retired: Previous Occupation:
Previous Industry:
Marital Status:
Single Married
Widowed Separated
Divorced Alternative Lifestyle
Does your spouse want to do studies?
Yes No
If your spouse is not interested in doing studies his/her occupation is still required below.
Spouse's Name:
*Occupation:
*Industry:
If Retired: Previous Occupation:
Previous Industry:
*Birth Date:
  /    /  (mm/dd/yyyy)
*Age:
Birth Date: (Spouse)
  /    /  (mm/dd/yyyy)
Age: (Spouse)
*Race:
Caucasian Black Hispanic
Asian Other
Race: (Spouse)
Caucasian Black Hispanic
Asian Other
*Education:
High School Some College
Undergraduate Graduate Degree
Trade School
Education: (Spouse)
High School Some College
Undergraduate Graduate Degree
Trade School
*Household Income:
Under $25,000 $25,000 - $34,999
$35,000 - $49,999 $50,000 - $74,999
$75,000 - $99,999 $100,000 - $149,000
$150,000 + Refused
Children:
# of male children:  
Male Children's Name Birth Date
  /    /  (mm/dd/yyyy)
  /    /  (mm/dd/yyyy)
  /    /  (mm/dd/yyyy)
  /    /  (mm/dd/yyyy)
# of female children:  
Female Children's Name Birth Date
  /    /  (mm/dd/yyyy)
  /    /  (mm/dd/yyyy)
  /    /  (mm/dd/yyyy)
  /    /  (mm/dd/yyyy)
Pets:
# of cats:
# of dogs:
Other pets:
Autos:
Year Make Model
New Leased Used
New Leased Used
New Leased Used
New Leased Used
Smoker:
Brand
Regular Menthol
Lite Ultra Lite
Number of packs per day
Smoker: (Spouse)
Brand
Regular Menthol
Lite Ultra Lite
Number of packs per day
Beer Drinker:
No
Yes
Brand
(most often only)
Beer Drinker: (Spouse)
No
Yes
Brand
(most often only)
Residence:
Own     Rent     Live at home
Other 
Electronics:
XBox 360 Nintendo Wii Play Station 3
MP3 Player Laptop Digital Camera
Plasma TV LCD TV DLP TV
Other
Medical Conditions: (HER)
Allergies
Asthma
Arthritis
Cancer      Type
Cholesterol
Colitis
COPD
Depression
Diabetes
Heart Disease
High Blood Pressure
HIV
Hormonal
Leukemia
Lung Disease
Migraines
MS
Obesity
Osteoporosis
PMS
Shingles
STD's        Type
Thyroid
Ulcers
Vascular Disease
Other  
Prescription Medicines:
Medical Conditions: (HIM)
Allergies
Asthma
Arthritis
Cancer      Type
Cholesterol
Colitis
COPD
Depression
Diabetes
Heart Disease
High Blood Pressure
HIV
Leukemia
Lung Disease
Migraines
MS
Obesity
Osteoporosis
Prostate
Shingles
STD's        Type
Thyroid
Ulcers
Vascular Disease
Other  
Prescription Medicines:
Notes:
Travel To:
Northern Suburbs (Glenview)
Northwest Suburbs
City
Downtown
Studies:
Daytime
Evening


Please click Submit only once.

 
4350 DiPaolo Center, Suite D1 - Glenview, IL 60025
Phone: (847) 390-7777 - Toll Free: (800) 390-7780 - Fax: (847) 390-7849

©2010 Accurate Data Marketing