EXECUTIVES     

SECTION A -- Contact & Demographic Information

Please fill out the form as completely as possible. 

1. How did you find us / Who referred you?
   
   Another Website (Please specify below)
   Bay Area Parent
   Bay GuardianBlog (Please specify which below)Craig's ListEast Bay ExpressEmail from us or a friendExaminerFacebookFlyerFriend/Family Member/Co-WorkerFrom an employee of Fleischman (Please specify below)From an Organization or School (Please specify below)MyspaceNoe Valley VoiceSFGate.comSF Gator (SFSU Newspaper)SF WeeklyValpac Mailer

   Please Specify Referral, Website, School, Organization or Employee:
   

    
2. What is your name, address & phone number?

   First Name	MsMr
   Last Name 	
   
   Street		
   City  	 	
   Zip Code		
   
   	      	          Ex:    415	  398-4140      
   Home Phone Number  	 
   
   Work or Cell Phone Number   	 
   
   
   From time to time, we send out advance notice of upcoming groups via email.
   To facilitate this, we ask that you provide us with an email address.
   Please be assured that we will only use this information to get in touch about
   marketing research sessions with FFR.
   
   Email Address	
   

3. Last education level completed?
   
   Please Select Some High School High School Graduate Some College Associate Degree (AA) College Graduate (BA, BS) Some Graduate School Graduate Degree (MA, MS) Some Post Graduate Post Graduate Degree (PhD)
   
   

4. Do you own or rent your current residence?
   
   Own	Rent

5. Please tell us which income range best describes your total annual household income?
   This information is very important for demographic purposes
   and will remain absolutely CONFIDENTIAL.
   
   Less than $10,000 $10,000 - $20,000 $20,000 - $30,000 $30,000 - $40,000 $40,000 - $50,000 $50,000 - $60,000 $60,000 - $70,000 $70,000 - $80,000 $80,000 - $90,000 $90,000 - $100,000 $100,000 - $150,000 $150,000 - $200,000 $200,000+ Refused
   
   

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SECTION B -- Professional Information

1. What is your primary occupation / job title?

2. What are your primary duties and/or roles for your company? (If applicable):
   
   
   
   
3. Do you work full time, part time or are you not working currently?:
   
   Full Time Part Time Not Working/Student/Retired
   
   
4. Who is your primary employer?:
   
   
   
   
5. In what industry is the company involved? (Many companies may fit into more
   than one category, but please choose what industry your company PRIMARILY works within. 
   So if you work at a Pharmacy for example, please select 'Retail' rather than 'Pharmaceuticals'.)
   
   
   Not Applicable Advertising, Marketing, Public Relations Architecture/Engineering Arts & Entertainment Business Services Computer Services Computer Technology/Electronics/Software Construction Consulting Consumer Services Distribution Education Financial (Banks, Investment, Accounting) Food Industry (Restaurant, Catering, Manuf, Distrib) Government (Law Enforcement, City, County, Federal) Hospitality (Hotel, Tourism, Travel) Internet (Graphic Design, Web Design, Dot Com) Import/Export Insurance Legal Manufacturing Media (TV, Radio, Newspaper, Magazine, Publishing) Medical (Hospital, Health) Non-Profit (Social Services - Non-Govt) Pharmaceuticals (Biotech, Drugs) Real Estate/Property Management Retail Telecommunications/Cellular Temporary or Personnel Services Transportation (Taxi, Airline, Train) Utilities (Electricity, Gas, Water) Wholesaling Other
   
   
6. Approximately, how many people are employed for the company WORLDWIDE?
   (Your best estimate is fine.)
   
   Not Applicable 1 2-10 11-50 51-100 101-250 250-500 500-1000 1000-5000 5000+
   
   
7. Do you use a computer at work? What type and what accessories do you use?
   (Check all that apply)
   
   IBM or compatible Desktop
   IBM or compatible Laptop or Notebook
   Apple Macintosh or compatible Desktop
   Apple Macintosh or compatible Laptop or Notebook
   
   PDA (Palm, PocketPC, etc) Internet Access Cellular Phone
   Digital Camera
   
   
8. Do you travel domestically or internationally for business purposes?
   If so, how many times in a year (on average)? (Record number)
   
   Domestic Travel Not Applicable Once a year 2-4 times a year 5-10 times a year 11-50 times a year More than 50 times a year  
   International Travel Not Applicable Once a year 2-4 times a year 5-10 times a year 11-50 times a year More than 50 times a year
   
   
9. What is your business address? (If applicable):

   Street		
   City  	 	
   Zip Code		
   
   

10. Lastly, we do groups and interviews during the day and in the evening after working hours.
    Our groups normally last no longer than two hours and you may always decline
    to attend if a specific group/interview does not meet your schedule.
    
    Are you able to attend: ?
    
    Day groups Evening groups Both Day and Evening groups
    
    

You're Finished!  Please move to the submission section below.

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FORM SUBMISSION

We appreciate your interest in our research groups and look forward to speaking with you.
Thanks again!

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