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Consumer and Business Professionals Panel

Join our Consumer Panel to take part in research studies for general consumers and professionals.


* = required field


Contact Information

Enter your contact information so we know how to get in touch with you!

Name *
Email *
Home Phone *
Work Phone
Mobile Phone
Address 1 *
Address 2
City *
County *
State *
Zip Code *

Demographic Information

Let us know a little bit about you and your household

Gender *

Date of Birth *


Race/Ethnicity *

Marital Status *

Do you have any children in your household? If so, you can enter Gender and Date of Birth for up to 3 children.
Child 1 Gender Date of Birth

Child 2 Gender Date of Birth


Child 3 Gender Date of Birth


Education *

Annual Household Income *

Primary Residence *
Residence Type *
Vehicle Make *
Vehicle Year

Employment Information

Tell us about where you work

Employment Status

What is your job title?

Occupation

Which of the following industries do you work in?

How many people are employed by the company you
work for?
What is the name of the company you work for?
Do you travel for business?

Consumer Information

Party Affiliation

What type of bank accounts do you have?
(Select all that apply)

Checking Account Savings Account
Retirement Account Investment Account
Other
Who is your primary banking institution?

Do you have credit cards issued by any of the following
companies?
(Select all that apply)

Visa MasterCard
Discover American Express
Diner’s Club Department Store
Bank of America Barclays
Capital One Chase
Citi US Bank
Gas Card Other
Who is your primary health insurance provider?

Do you have any of the following conditions?
(Select all that apply)

ADHD Diabetes – Type 1
Allergies Diabetes – Type 2
Arthritis Heart Condition
Asthma High Blood Pressure
Cancer – Breast High Cholesterol
Cancer – Colon HIV/AIDS
Cancer – Prostate Migraine Headaches
Cancer – Other Obesity
Chronic Pain Depression/Anxiety
Other health conditions

Do you provide care for someone with any of the following conditions?
(Select all that apply)

ADHD Diabetes – Type 1
Allergies Diabetes – Type 2
Arthritis Heart Condition
Asthma High Blood Pressure
Cancer – Breast High Cholesterol
Cancer – Colon HIV/AIDS
Cancer – Prostate Migraine Headaches
Cancer – Other Obesity
Chronic Pain Depression/Anxiety
Other health conditions
What type of television service do you have at home?
Who is your television service provider?
Who is your cellular service provider?
Do you own a smartphone?
(BlackBerry, iPhone, Android, etc…)

What type of internet connection do you have at home?

Which of the following devices do you own?
(Select all that apply)

Desktop Computer Laptop Computer
Tablet Computer Mp3 Player
DVD Player Blu-Ray Player
HDTV Video Game Console

Do you smoke?

Do you own any pets?
(Select all that apply)

Dog
Fish Reptile
Other

Which of the following do you drink?
(Select all that apply)

Beer Wine
Liquor Soda
Coffee Tea
Bottled Water Energy Drinks
Sports Drinks

Do you enjoy listening to any of the following on the radio?
(Select all that apply)

Classic Rock Classical Music
Country Easy Listening
Gospel Hip-Hop
Jazz News
NPR Religious
Spanish Music Spanish Sports
Spanish Talk Sports
Talk Top 40
Other

Are you a member of any of the following hotel rewards programs?
(Select all that apply)

Choice Hotels Club Carlson
Hilton Hyatt
IGH Rewards Kimpton
Marriott Starwood (SPG)
Wyndham Other

How did you hear about Engage?

If you heard about us from a friend or colleague, please enter their name or email address here: