Shifrin~Hayworth
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For a company to provide what their customers want and need, it must first understand those needs. In order to understand the needs of consumers like you, companies conduct market research studies. These studies take many forms, including one-on-one interviews, telephone interviews and focus groups. Studies typically last from 30 minutes to three hours and pay anywhere from $50 to $250 depending on the client, length and topic. Shifrin~Hayworth conducts all kinds of studies for our clients. One way in which we serve our clients is by recruiting people like you to give their opinions. Our clients need your opinions and they are willing to pay you for them.

When you register to participate in our marketing research studies, your information is placed in our confidential database. We will then contact you when we have a study that we'd like to pay you to participate in. Since our studies can include all types of people, you can register your entire family to participate, as well as your friends and relatives. By filling out the questionnaire below, you are providing us with the information we need to choose the right studies for you to participate in. You do not have to fill out every field, but the more information you give us the better chance you have of being chosen to participate. Before giving us any information, please read our privacy statement.

If you are not comfortable with providing this information online, please print this page, fill it out manually, and mail it to:

Shifrin-Hayworth, Inc
26400 Lahser Road, Suite 430
Southfield, MI 48033

General Information
First Name:   Last Name:  
Sex:   Male Female

Birthdate:

Address:   City:  
State or Province:  
Postal Code:   Email:  
Please state all phone numbers in the form of the example: (000) 123-4567
Home Phone:   Work Phone:  
Ethnic Background 1:
Secondary Ethnic Background:
Education Level:
Total Household Income Before Taxes:
Occupation:   Industry:  
Work Status:   Part-Time Full-Time Not Employed
Check when available to participate in research projects:   Morning   Afternoon   Evening   Weekends

Product and Service Usage Information
Which of the following electronic equipment do you own?
VCR Home Computer
Scanner DVD Player
Cellular Phone Compact Disc Player
Pager Internet Access
Cable T.V. Camera
Satellite Dish
Check if you own: Check if you own:
Dog  Cat Sailboat  Powerboat  Yacht

Vehicle Ownership (List up to 2 vehicles per household)
Model Year Manufacturer

Groceries and Beverages
Which of the following foods do you purchase?
Diet Foods Health Foods
Which of the following beverages do you purchase?
Soft Drinks List 2 Favorites:   
Sparkling/Flavored Carbonated Water     Wine     Liquor
Beer List 3 Brands:    
How many 6-Packs of Beer do you buy a month?  

Medical Conditions
Please list any medical conditions that you or your family have (Up to 6)
Type of Condition: Family Relation:

Cigarettes
Is anyone in your family a smoker?
Yes No
Please list all brands smoked by members of your household
Brand Name: Size (100's, Kings, Reg, etc.): Family Member:

Other Activities
How often do you eat at Restaurants?
Fast Food:
Sit Down Restaurants:
Do you have any dietary restrictions that limit the type of foods eaten by you and your family?
Yes No If Yes, please explain:  
Do you or any adult member of your household exercise on a regular basis?
Yes No
How many trips have you taken in an average year?
Total number of trips:
How Many for Business?
How Many for Pleasure?
Are you a registered voter?  Yes No
What party do you usually vote for in each of the following types of elections?
Local   State   National  
Do you have any financial investments (other than property)?
Yes No
Do you own or rent your home?
Own Rent
Answer the following ONLY IF YOU OWN A HOME:
When was the last time you remodeled your home (MM/YY)?  
When did you buy your last home (MM/YY)?  

Media
What 4 radio stations do you listen to most often?
What 4 magazines do you read most often?
What 4 favorite hobbies do you and your family members participate in?

Organizations
Please list any organizations that you or your family members belong to.

Family Information
Spouse or Partner:
First Name:   Last Name:  

Spouse Birthdate:

Occupation:   Work Phone:  
Industry:  
Children:
Please list sex and birth date of all children in your household (Up to 4 chidren):
Sex Birth Date  :
Male Female

Male Female

Male Female

Male Female


Thank you very much for filling this questionnaire. We look forward to having you participate in one of our research studies. If you have any friends or other family members you think would be interested in marketing research please give us their Name, Address, and Phone Number below so we can send them one of our forms. You may also either have them fill out this form online or you may print this electronic form and have them send it to:

Shifrin~Hayworth
26400 Lahser Road, Suite 430
Southfield, MI 48033


NOTE: Please do NOT fill in your own information below. It will not result in you being picked more often, and it could result in your questionnaire being rejected altogether. If you are using a program (such as RoboForm) and it has inserted your information, you MUST remove it.


Friend 1
Name:
Address:
City:
State or Province:
Postal code:
Home Phone:
Friend 2
Name:
Address:
City:
State or Province:
Postal code:
Home Phone:
Friend 3
Name:
Address:
City:
State or Province:
Postal code:
Home Phone:
Friend 4
Name:
Address:
City:
State or Province:
Postal code:
Home Phone:
   

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