Adler-Weiner Research Company

6500 North Lincoln Ave., Lincolnwood, IL 60712
Tel. (847) 675-5011, Fax. (847) 675-5698, Email: info@awres.com
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Consumer's Questionnaire

Dear Consumer:

We at Adler-Weiner Research have been asked to speak with consumers and professionals 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 !

IF YOU WOULD LIKE TO UPDATE AN EXISTING PROFILE
PLEASE CALL US AT 847-675-5011
 

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

*Primary #:

 Secondary # :
Third # : 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:
*Title:
*Occupation:
*Industry:
*Company:
*# Local Employees:
*# Total Employees:
*Annual Sales:
*Do You Travel Domestically For Work? Yes  No   # of trips per year

*Do You Travel Internationally For Work? Yes  No   # of trips per year

COMPUTERS/INTERNET
*Do You Use a PC/MAC at home?

Yes   No
*Do You Use a PC/MAC at work? Yes   No
*Brand of your computer at home:
*Brand of your computer at work:
*On-Line Provider:
*Internet Connection Speed:
*Gaming Systems:  
*Game Types:  

*Do You Own a Car? Yes   No

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

Do You Own a Credit/Charge Card? 

Complete Fields Below for Each Card Owned:

Yes   No

  

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
Do You Have Cable? Yes   No
What is your Political Party?
Do You Drink Any of the Following Beverages:
Select all that apply ...
Please name your 3 favorite radio stations
Radio Station 1:
Radio Station 2:
Radio Station 3:
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
Do You Have Any Medical Conditions? Yes   No
Medical Conditions 1:

If you have any other medical conditions

complete fields below.

Medical Conditions 2:

 

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

How did you hear about Adler-Weiner Research Company?

If 'Other' please explain:


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