General Details

*Title: ? Mr Mrs Ms Miss
*First Name:
*Last Name:
*Door Number or House Name:
*Address:
*Postcode:

*Date of Birth (DD/MM/YYYY): / /

*Marital Status: ? Married Single Co-habitiing Separated Divorced Widowed

*Gender: ? Male Female

Contact Details

Home Telephone Number:
Mobile Telephone Number:
Work Telephone Number:
*Best Number to Contact You (This should be one that you can be reached most of the time): ? Home Mobile Work

*Email Address:

Personal Details

There are no mandatory fields in this section, but the more complete and accurate answers you can supply the more lmarket research projects we may be able to give you.

Living and Family

Type of Property Lived in: ? House Flat Bungalow
The Property is: ? Freehold LeaseHold Rented

Are you Head of The Household: ? Yes No
Job Title:
Your Income Band: ? £0 -£14999 £15000 - £24999 £25000 - £34000 £35000 - £49999 £50000 - £74999 £75000+
Are you one of the main decision makers in your firm for purchasing products or services: ? Yes No

How many children do you have: ? 0 1 2 3 4 5
How many are Male: ? 0 1 2 3 4 5
How Many are Female: ? 0 1 2 3 4 5
Age of the Oldest Child:

What is your Highest Level of Education: ? Secondary College University Post graduate
What is your Highest Qualification:

What Pets Do You Have:

Do You Smoke: ? Yes No

Wear Glasses: ? Yes No

Wear Contact Lenses: ? Yes No

Are you Vegetarian: ? Yes No

Products

Mobile Tariff: ? Contract Pay as you go
Mobile Network:

How Many Cars Do You Own: ? 0 1 2 3
Car1: Make Model Year Fuel Type Ownership Type ? Private Company Leased Ex demo
Car 2:Make Model Year Fuel Type Ownership Type ? Private Company Leased Ex demo
Car 3: Make Model Year Fuel Type Ownership Type ? Private Company Leased Ex demo

Do you have any of the following (Tick all that apply):

Sky Freeview Cable Digital TV
Broadband Computer at Home  Internet Telephone
PDA MP3 Player iPOD Satellite Navigation

Who Do You Bank With:
Who Do You Bank With Online:

Which of the Following Do You Drink:

Tap Water Bottled Water
Fruit Juice Smoothies Fizzy Drinks
 Lager Beer Wine Spirits Champagne

Other

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