Granite State Marketing Research


Potential Participants Questionnaire


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Please fill out the form below to register as a potential survey and / or focus group participant.
All information gathered by GSMR is always kept strictly confidential. We do not sell information and / or mailing lists whatsoever.

Please identify and describe yourself:

First name
Last name
Age
Sex Male Female

Please provide the following contact information:

Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Home Phone
E-mail

Are you married or single?

Married
Single

How many children do you have? What are their ages?


Please choose your level of education:

Some High School
High School Graduate
Trade or Technical School
Some College
College Graduate
Post Graduate

What is your occupation?


If married, what is your spouse's occupation?


What is your total household income?


What is your political affiliation?


What brands of beverages do you drink?


What brand of beer do you drink?


What are your hobbies?


What type of music do you listen to?