*First Name: 

*Last Name: 

*Company Name: 

*City:

 *State/Province:

*What time zone do you live in?

*Company or Home Address 1:

Address 2: 

*Country:

*Age:

  Please select 12-17 18-24 25-34 35-44 45-54 55-64 65-over

*Sex:

  SELECT HERE MALE FEMALE

Race: 
 (for demographic purposes only, NOT REQUIRED)

 
  SELECT HERE Caucasian African American Hispanic Asian Native American Other

*Marital Status:

  SELECT HERE SINGLE MARRIED DOMESTIC PARTNER

*Total number of adults living in household:

*Number and ages of children living in the household over the age of ten:

 *Occupation:

*Annual Household Income:

  Please select Less than $15,000 $15,000-$30,000 $31,000-$45,000 $46,000-$60,000 $61,000-$75,000 $76,000-$90,000 $91,000-$105,000 $106,000-$120,000 More than $120,000

*Education:

*Have you ever participated in market research before?

*Home or Office Phone:

*Email Address:
(please be sure your email is correct)

*Do you have a telephone near your computer? (hands free okay):

*What type of computer do you own?

*What is your Operating System type in your Computer? 

*What type of Internet Connection do you currently use in your home?

*What type of Internet Connection do you currently use in your business?

*What Internet Browsing/Surfing program is on your computer? 

*Do you use a Parental Control Software for the Internet? 

*What is the name of your ISP or Internet Provider?
(i.e. Bellsouth DSL, Comcast Cable DSL, AOL Broadband)  

*Do you use a POP UP Blocker?
(used to stop ads from popping onto your screen during use)

*Do you currently own a webcam?

If yes, what webcam brand and model?
(ex: Logitech QuickCam Orbit. Model Number 961310-0403 )

*How did you find out about us, or your contact person?

I would like to participate in a video/audio focus group.  You will receive a free webcam and headset mic as well as monetary compensation if you qualify.
 

 
  SELECT HERE YES NO

I would like to participate in a Voice Over IP audio message board focus group. You will receive a free headset mic and monetary compensation if you qualify.
 

 
  SELECT HERE YES NO

I would like to participate in both of the above focus groups.

  SELECT HERE YES NO