Focus Group Application

Your Name

Your Address

Your Email

Your Phone

Your Gender
MaleFemale

Your Age
18-2526-3536-4546-5555+

Your Education
Grade SchoolHigh School/GEDSome CollegeCollege GraduatePost Graduate Degree

Are you employed?
YesNo

What type of work do you do?

Have you served in the Military?
YesNo

Are you married?
YesNo

Do you have children?
YesNo

Your Income
>$20,000$20,000-$35,000$36,000-$50,000$51,000-$100,000$100,000+

Have you ever participated in a Focus group before?
YesNo

Have you ever served on a jury before?
YesNo

Have you ever been a party to a law suit before?
YesNo

Have you ever been arrested?
YesNo

When are you available to participate in this Focus group?
Mon–Fri 8–5Mon-Fri Evenings after 5pmWeekends

Do You Use PayPal or Venmo?
PaypalVenmo

PayPal or Venmo Account Information for Payment: