*First Name:

*Street Address:

*State:

*Home Phone:
- -
 Work Phone:
- -

*Last Name:

*City:

*Zip Code:

 Cell Phone:
- -
*Email:

*Date Of Birth:
 -  -

*Gender:
 Male Female

*Education:


*Marital Status:


*Religious Affiliation:  


*Primary Banking Institution:  

*Ethnicity:
White/Caucasian
Black/African American
Hispanic/Latino
Asian
Pacific Islander
Native American
Other
   If Hispanic, what is your
   Dominant Language:
    
   If Hispanic, what is your Country/Region
   of Origin:
    
   If Asian, Country/Region of Origin:
    

*Pets:   
  Dog(s)  Cat(s)  Bird(s) 
  Other(s)  None 

Politics
*Currently Registered to Vote?
  Yes No
*Voting Pattern:  
*Party Affiliation:  

*Employment Status:


*Position/Title:


*Income:

*Industry:

   
  If "Other", please describe:

Child (1): Date Of Birth:  -  - / Gender: Male Female
Child (2): Date Of Birth:  -  - / Gender: Male Female
Child (3): Date Of Birth:  -  - / Gender: Male Female
Child (4): Date Of Birth:  -  - / Gender: Male Female

Television

*What is your favorite type of TV programming:
1.
2.
3.

*Total Number of TV hours per week:
*Total Number of Cable TV hours per week:
*Total Number of PrimeTime (8pm - 11pm) TV hours per week:
*Total Number of Late Night (11:30pm - ) TV hours per week:

Movies

*What is your favorite type of movie:
1.
2.

*Number of Movies seen in a theater in the past two (2) months:
*Number of Movies seen in a theater in the past twelve (12) months:
*Number of DVD's purchased in the past two (2) months:
*Number of DVD's purchased in the past twelve (12) months:

Do you have:

*Cable Television: Yes No
 *Flat screen (Plasma or LCD/DLP)
  Television: Yes No
 
*Satellite Television: Yes No
 *Are you aware of Blu-Ray/HD DVD?
   Yes No
*DVD Player: Yes No
     Do you own a Blu-Ray/HD DVD Player?
   Yes No
*TIVO or DVR: Yes No


*Video Game System: Yes No *MP3 Player: Yes No
 
   If yes, which game console(s):
   1.
   2. 		*Video iPod: Yes No



*Home Computer: Yes No
*Cell Phone: Yes No
  Which Computer Platform:
   
*iPhone Yes No
*Internet Access: Yes No   Who is your cell phone service provider:    
  Internet Connection Type:
   
*Is your cell phone your primary phone:
  Yes No

 
*Have you participated with us in a
  focus group before?
   		*How did you hear about us?
  
  If "Yes", date of participation:
  

I understand that Advanced Marketing Perspectives may use the information that I provided to contact me for market and opinion research studies in the future. My information will only be used by Advanced Marketing Perspectives.
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