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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Professional's Questionnaire

Dear Professional:

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
*First Name: *Last Name:
*Home # : Work # :
Cell # : Pager # :
Fax # :    
*E-Mail: *Confirmation E-Mail:
*Address: Apt./Suite:
*City: *State:
*Zip:    
Ethnicity: *Date of Birth: / /
Gender:
   
Which Location Will You Go To?
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 at home? Yes   No
Do You Use a Mac at home? Yes   No
Do You Use a PC at work? Yes   No
Do You Use a Mac at work? Yes   No
Brand of your computer at home:
Brand of your computer at work:
On-Line Provider:
Internet Connection Speed:
CARS DRIVEN - please indicate most recent 2 automobiles.
Make: Model: Class: Year:
Make: Model: Class: Year:
Please click Submit only once.