Participate: Respondent Questionnaire
 
Want to get involved and benefit from being in our database? With a database of over 100,000 participants, we are sure that you will notice the excellence in our research.

Disclaimer: Miami Market Research assures you that any information you provide below will remain confidential and will be used for classification purposes only. We will never sell your information to other companies or attempt to contact you to sell you anything. Also, you may refuse to answer any part of this questionnaire. Thank you, the MMR team.

Are you?
(required)		 A first time participant
Just updating your information
Name (required):
Address (required):
City (required):
State:
Zip (required):
Home phone:
Cell phone (required):
Work phone:
Email:
Gender: Male
Female
Sexual Orientation: Heterosexual
Bisexual
Homosexual
Date of Birth:
Marital Status:
Ethnicity: Hispanic
Caucasian
African-American
Asian
Other
From what country
does your family originate?
Education:
Language: English
Spanish
Bilingual
Multilingual
What is your political affiliation?
Health Insurance Provider:
Medical Conditions:
Smoker? yes
no
Do you rent or own your home?
If you own a home, what company
provides you with home insurance?
Do you lease or own your car?
What company provides you
with auto insurance?
What are the Make, Model
and year of your car(s)?
What company provides you with
Local phone service for your home?
What company provides you
with cell phone service?
Who is your Internet Service Provider?
What is your occupation?
(if teacher please indicate grade and school)
What company do you work for?
What is your annual household income? Under 10K
10-20K
20-30K
30-40K
40-50K
50-60K
60-70K
70-80K
80-90K
90-100K
100-200K
200-300K
over 300K
What company provides you
with banking service?
Check all of the types of accounts
that you have		 Checking Account
Savings Account
Investment Account
Credit Card
If you have children,
specify their gender and age:
Do you have cable or satellite? Cable
Satellite
Other

Thank you for your time and interest
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