GAMERS     

SECTION A -- Personal & Household 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 Phone Number   	 
   
   Cell Phone Number   	  
   
    From time to time, we send out advance notice of upcoming groups via text 
   message. Click here if you would like to receive these notifications. Please be
    assured that we will ONLY send you information about future marketing research
    sessions with FFR.
   
   
   More often, 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. What is your birthdate? (Please be honest as it is
   very important for demographic purposes.)
   
   (Please list in this format: MM/DD/YYYY
   Example: 09/09/1940 - NO PERIODS OR SPACES)
   
   
   

4. What is your marital status?:
   
   SingleMarriedDivorcedSeparatedWidowed
   

5. What is your current living situation?
   
   Live Alone Live with Spouse Live with Significant Other Live with Roommate(s) Live with Parent(s) Live with Family (not parents)
   
   
6. 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)
   
   

7. What is your ethnic background?
   
   African AmericanAsianCaucasianHispanic/LatinoFilipino / Pacific IslanderNative AmericanOther
   

8. Please tell us which income range best describes your total annual household income? (Meaning everyone in your household combined.
   Your best guess is fine.)
   
   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
   
   
   
9. Do you work full time, part time, are you a student or are you not working currently?:
   
   Full Time Part Time Not Working Full-Time Student 
   PT / Also a Student
   
   
10. If employed, what is your primary occupation / job title?

11. If employed, who is your primary employer?
    

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SECTION B -- Technology, Music & Gaming

1. What are your favorite radio stations? List up to four in the spaces provided.
   (Please list call letters, if possible.) 
   
   Ex: KLLC           KITS
              
   
   
2. Do you own a home computer or Video Game System? What type and what
   other accessories do you own?
   (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 IPod or Other Portable Music Player
   
   Nintendo DS Nintendo GameCube  Nintendo Wii Sony PS2 
   Sony PS3 Sony PSP   Xbox Xbox 360   PC Games
   
   

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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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