Adler-Weiner Research Company

6500 North Lincoln Ave., Lincolnwood, IL 60712
Tel. (847) 675-5011, Fax. (847) 675-5698, Email: info@awres.com
CLIENTS
HOME
ABOUT
FACILITIES
RECRUITING
ZIP CODES
TECHNOLOGY
DIRECTIONS
LOCAL HOTELS
CONTACT US
Participant
Sign-Up
GENERAL INFO
CONSUMERS & PROFESSIONALS
PHYSICIANS

Consumer's/Professional's Questionnaire

Dear Consumers/Professionals:

We at Adler-Weiner Research have been asked to speak with consumers in depth about the products or services that you are using or those products and services that are still under development.  Your opinions are vital to this process and will help us understand how to serve you best. Please take the time to fill out this brief questionnaire; it is for our demographic records ONLY.

PLEASE REFER TO OUR ZIP CODES PAGE TO VERIFY YOU LIVE WITHIN THE COVERAGE AREA. PLEASE LINK TO THE FOLLOWING APPROPRIATE AREA:
CHICAGO OR THE IMMEDIATE SURROUNDING SUBURBS OR SUBURBAN AREA RESIDENTS.

WE ASK YOU TO NOTE, THAT CURRENTLY, ADLER WEINER RESEARCH DOES NOT DO ANY ONLINE STUDIES, SO PLEASE SIGN UP TO PARTICIPATE ONLY IF YOU ARE ABLE TO JOIN US AT OUR FACILITY.

THANK YOU !

INDIVIDUALS WHO HAVE AN EXISTING PROFILE CANNOT UPDATE THEIR PROFILE ONLINE.

YOU MUST CALL 847-763-5620 TO UPDATE.
 

GENERAL INFORMATION
* - denotes required fields
*First Name: *Last Name:

You must include at least one phone number.

Home #:

Work # :

Cell # : Pager # :
Fax # :    
*E-Mail: *Confirmation E-Mail:
*Address: Apt./Suite:
*City: *State:
*Zip:    
*Ethnicity: *Date of Birth:
/ /
*Gender: *Marital Status:
*Education: Hair Color
 *Which Location Will You Go To?  
*Personal Income:  *Household Income: 

*Housing Status:

*Housing Type:
CHILDREN INFORMATION  
*Do you have children under the age of 18 living in your home? Yes   No
Name: Gender: DOB:
/ /
Name: Gender: DOB:
/ /
Name: Gender: DOB:
/ /
Name: Gender: DOB:
/ /
Name: Gender: DOB:
/ /
Name: Gender: DOB:
/ /

EMPLOYMENT
*Employment Status:
*Work Title:
*Occupation:
*Industry:
*Company:

*# of Local Employees:
*# of Total Employees:
*Annual Sales:
*Number of domestic work trips per year:
*Number of international work trips per year:

COMPUTERS/INTERNET

*Brand of  computer used at home?

(choose none if appropriate)

*On-Line Provider:

*Internet Connection Speed:

*Gaming Systems:

*Game Types:

Complete Information for Car YOU Drive Most Often:

 Make:

Model:

Class:

Year:

If Additional Car in Household (yours, spouse's, child's, other) 

Complete Fields Below:

Make:

Model:

Class:

Year:

CREDIT CARD INFORMATION

Complete Fields Below for Each Card Owned: 

  

Credit Card 1: 

Credit Card 2: 
Credit Card 3: 
Credit Card 4: 

TELEPHONE INFORMATION

Local Telephone Carrier:
Long Distance Carrier:

  Cell Phone Provider:  
MISCELLANEOUS INFORMATION

TV, Cable, Satellite Provider:

What is your Political Party?
Do You Drink Any of the Following Beverages?:
Select all that apply ...
CIGARETTES
Do You Smoke Cigarettes? Yes   No
Primary Brand

Alternate Brand

Flavor

Length

Type

PETS
Do You Have Any Pets? 1:
Do You Have Any Pets? 2:
Do You Have Any Pets? 3:
Do You Have Any Pets? 4:
Do You Have Any Pets 5:

MEDICAL CONDITIONS

Medical Conditions 1:

Medical Conditions 2:

Medical Conditions 3:
Medical Conditions 4:
Medical Conditions 5:

How did you hear about Adler-Weiner Research Company?

Please click Submit only once.

 

 

If you click Reset

all data is cleared!