Thank you for your interest in participating in studies conducted by Cook Research & Consulting, Inc. Please note that participation in our projects is geographically limited to residents of Minnesota only.

Registration involves three easy steps:

• Gather information about you.
• Gather information about others in your household.
• Gather information about your household.

If you are already in our database and would like to update your information, please complete the registration; and we will update your file.

This information will be used exclusively for finding appropriate people for research studies. It eliminates many attempts to contact persons not qualified for particular projects. Cook Research & Consulting, Inc. respects your privacy; all of your information given to us is confidential and used only for marketing research purposes.

We ask that people make a firm commitment and agree to participate. We promise our clients a certain number of people for each project. When people do not show up, we miss our target with no opportunity to find a replacement for them. If the need arises, we expect a call to cancel in time for us to find a replacement. But most of all, we want to be able to count on those who have agreed to participate to arrive on time and to contribute.

 

First Name

Last Name

E-Mail :

Home Phn:

Alt. Phn:

Address Apt. Suite

City Zip Code

Own Home Rent Live with Family / Friends

Date of Birth Gender Female Male

Marital Status Married Single Divorced/Seperated Partner

Occupation Industry

Company Name Status Full-time Part-time Self-Employed Entrepreneur

Spouse/Partner's First Name

Spouse/Partner's Last Name

Date of Birth Gender Female Male

Highest Degree of Education Completed

Spouse/Partner's Occupation

Industry

Company Name Status Full-time Part-time Self-Employed Entrepreneur

Children under 18 years old living at home

Gender Female Male Date of Birth

Gender Female Male Date of Birth

Gender Female Male Date of Birth

Gender Female Male Date of Birth

Gender Female Male Date of Birth

Please list the Brand (s) of items that you own:

Automobile

Motorcycle or Scooter

Computer Printer

How do you access the internet?

Dial- Up Phone Modem Cable Modem DSL

Do you use a wireless connection? Yes No

Please check any of the following that you own or subscribe to:

Cell Phone Digital Camera Digital Camcorder Laptop Computer Handheld / PDA IPod / MP3 Player GPS Device Cable or Satellite TV

Please list any pets you own?

Do you speak any languages other than English? (Fluently) Yes No

Typically when voting - do you vote as? Republican Democrat Independent Other Not Registered

Genre most often listen to on the radio ?

Alternative Blues / Jazz Classic Rock Classical Country Hard Rock Light Rock News / Talk Oldies

 

Total Family Income :

Under $20,000 

$20,000-$29,999 

$30,000-$49,999

$50,000-$74,999

$75,000-$100,000

Over $100,000

 

Education :

High School

1 Yr. College

2 Yr. College

3 Yr. College

College Graduate

Vocational

Post Graduate

 

Ethnic Background :

Caucasian

Hispanic

Native American

African American

Asian

Other   

 

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