Register to Participate in a Focus Group with Group Insight

Demographic Information

Please provide the following basic demographic information. Any information provided will be kept strictly confidential and for research purposes only.

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* 1. Please provide your contact information:

Name *

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code *

Email Address

Phone Number *

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* 2. What is your Gender?

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* 3. Which category below includes your current Age?

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* 4. Are you White, Black or African-American, Spanish/Hispanic/Latino, American Indian or Alaskan Native, Asian, Native Hawaiian or Other Pacific Islander, or some other race?

Register to Participate in a Focus Group with Group Insight

Demographic Information

Question Title

* 1. Please provide your contact information:

Question Title

* 2. What is your Gender?

Question Title

* 3. Which category below includes your current Age?

Question Title

* 4. Are you White, Black or African-American, Spanish/Hispanic/Latino, American Indian or Alaskan Native, Asian, Native Hawaiian or Other Pacific Islander, or some other race?

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* 5. What is the highest level of school you have completed or the highest degree you have received?

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* 6. How would you best describe your political affiliation?

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* 7. What is your current Occupation and Job Title?

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* 8. Which of the following best describe your current relationship status?

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* 9. How much total combined money did all members of your HOUSEHOLD earn last year?

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* 10. How many children are you parent or guardian for and live in your household (aged 17 or younger only)?

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* 11. What is your current religion, if any?