Adler-Weiner Research Company

875 N. Michigan Ave., John Hancock Center, Suite 3260, Chicago, IL 60611
Tel: (312) 944-2555, Fax. (312) 944-7812, Email: info@awres.com
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CONSUMERS & PROFESSIONALS
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Consumer's/Professional's Questionnaire

Dear Consumers/Professionals:

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
Suburban area residents

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:
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Name: Gender: DOB:
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Name: Gender: DOB:
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EMPLOYMENT
*Employment Status:
*Work Title:
*Occupation:
*Industry:
*Company:

*# of Local Employees:
*# of Total Employees:
*Annual Sales: