The MSR Group - A Market Research Company

Participation Form

Your opinions are the key to many marketing decisions. The MSR Group is often asked by product manufacturers to talk to consumers in depth about the products they use or new products being developed. If you would like to be considered for future research studies, please fill out and submit the online form below. Participants are often compensated for their participation. Please understand that the personal information you volunteer is necessary to determine your qualifications for the various research studies we conduct. All information is kept strictly confidential and used only to assist in your recruitment.

PERSONAL INFORMATION

*First Name:

*Birth Date:

*Last Name:

*Home Phone:

*Street Address:

Work Phone:

*City:

Cell/Pager:

*State:

*E-Mail Address:

*Zip:

*Gender:

*County:

Race:

Caucasian
African American
Hispanic
Asian
American Indian
Other

Marital Status:

Single
Living W/Significant Other
Married
Divorced
Separated
Widowed

Are You Employed:

Full Time
Part Time
Homemaker
Retired
Unemployed

Education:

0-8th Grade
Some High School
High School Grad
Some College
4 Year Degree
Grad School
Tech School

Company Name:

Type Of Industry:

Job Title:

Are You Registered To Vote:

Yes
No

Party Affiliation:

Democrat
Republican
Independent
Other

Into which of the following categories does your total annual household income fall:

Less Than $10,000
$10,000 - $19,999
$20,000 - $29,999

$30,000 - $39,999
$40,000 - $49,999
$50,000 - $59,999

$60,000 - $69,999
$70,000 - $79,999
$80,000 - $89,999

$90,000 - $99,999
$100,000 - $200,000
Over $200,000

List one radio station for music that is your favorite in the omaha metro area:

List any medical conditions such as allergies, diabetes, heart problems, special needs, etc:

Which area Hospital would you prefer to go to for your healthcare needs?

Do you play lottery:

Yes No Scratch Powerball Both

Housing:

Rent Own

Do you have any children still living at home?

Yes No

Fields with an asterisk (*) are required. Please make sure to fill them before continuing.

The MSR Group - 1121 N. 102nd Ct. Suite 100 Omaha, NE 68114
t: 402.392.0755 :: 1.800.737.0755 :: f: 402.392.1068