Participant Information Form

Elliott Benson Research is an organization interested solely in collecting opinions. As a participant in one of our studies, you could help to create new products, services, advertising, or possibly impact decisions in the local government, and the best part is that you'll be paid for your opinions!

Please keep in mind that some of our clients seek participants who meet very specific needs, so the more we know about you, the more likely we are to contact you for our studies!

We keep all information strictly confidential and we never sell our database to outside sources.

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* 1. Contact Information

First Name *

Last Name *

Address

Address 2

City *

State *

ZIP/Postal Code *

Email Address *

Primary Phone Number *

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* 2. What is your gender?

Female

Male

Other (please specify)

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* 3. What is your age?

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* 4. What is your birthdate? Please use the format MM/DD/YYYY

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* 5. Which of the following best indicates your ethnicity?

Asian

African American

Hispanic or Latino

Pacific Islander

Caucasian

Native American

Other

Prefer not to answer

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* 6. What is your current marital status?

Married

Single

Divorced

Widowed

Living Together

Other

Prefer not to answer

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* 7. Which of the following best represents your current employment status?

Working Full Time

Working Part Time

Homemaker

Self Employed

Full Time Student

Retired

Unemployed

Prefer not to answer