Survey Participants:

Thank you for your interest!

In order to participate in one of our studies, you need to reside in Palm Beach, Broward, Martin, or St. Lucie counties. We will ask you to provide information about yourself and your household.

It is the policy of Palm Beach Focus to protect the identity of our research participants. Your identity and any personal demographic information will be held confidential and never be used for reasons outside the scope of our research.

Our research projects are conducted strictly for research purposes only and we will never conduct any sales effort nor solicitation.

If you are a new participant and would like to enroll in our research panel, please complete the Online Registration Form or call our office at 561-640-3412 to speak with a recruiter.

If you are already in our database and would like to update your information, please complete the following Online Registration Form:

ONLINE REGISTRATION FORM

ARE YOU: Male
Female

FIRST NAME: *

LAST NAME: *

HOME ADDRESS:

APT #:

CITY:

STATE:

ZIP CODE:

HOME PHONE:

WORK PHONE:

CELL PHONE:

FAX:

EMAIL ADDRESS: *

AGE:

BIRTH DATE:

ETHNIC BACKGROUND: African American/Black
American Indian
Asian
Caucasian/White
Haitian/Black
Latino/Hispanic
Islander
Other

MARITAL STATUS: Never Married
Separated
Divorced
Married
Living w/Significant Other
Widowed

EDUCATION: Less than High School Grad
GED
High School Grad
Vocational/Tech School
Some College/No Degree
2-Year Degree
4-Year Degree
Some Graduate Work
Post Graduate

HOUSEHOLD INCOME: Under $20,000
$20,000-$30,000
$30,000-$40,000
$40,000-$50,000
$50,000-$60,000
$60,000-$75,000
$75,000-$100,000
$100,000-$150,000
$150,000+

EMPLOYMENT STATUS: Unemployed/Seeking Work
Homemaker
Fully Retired
Semi-Retired
Working Full-Time
Working Part-Time
Full-Time College Student
Part-Time College Student

CURRENT OCCUPATION:

CURRENT EMPLOYER:

CURRENT INDUSTRY:

PREVIOUS OCCUPATION:

PREVIOUS EMPLOYER:

PREVIOUS INDUSTRY:

REGISTERED TO VOTE IN FLORIDA: Yes
No

POLITICAL AFFILIATION: Democrat
Independent
Republican
Other
None

DO YOU: Rent
Own
Live w/Parents

YOUR PRIMARY AUTOMOBILE YEAR:

YOUR PRIMARY AUTOMOBILE MAKE:

YOUR PRIMARY AUTOMOBILE MODEL:

DO YOU HAVE CHILDREN: Age 0-5
Age 6-9
Age 10-12
Age 13-15
Age 16-18

HOW DID YOU HEAR ABOUT PALM BEACH FOCUS?

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