Las Vegas Field and Focus

3909 S.MARYLAND PARKWAY, 4th FLOOR, LAS VEGAS, NV. 89119
Office (702) 733-0305 Fax (702) 733-6649

EVERYONE HAS AN OPINION.
$$ WHY NOT GET PAID FOR YOURS? $$

COMPLETE ONE FORM FOR EACH FAMILY MEMBER
This information is to be used exclusively to recruit participants for surveys and focus groups.
Call us if you have any questions.

Name:
Address:
City:
State:
	Example: "NV" for Nevada.
Zip Code:
	Example: 00000 or 0000-00000.
Home Phone:
	Example: 000-000-0000.
Cell Phone:
	Example: 000-000-0000.
Work Phone:
	Example: 000-000-0000.
Do You:	Rent Own
Age:
Birthdate:
	Example: January 01 1900.
Ethnic Background:
Occupation / Job Title:
Company / Industry:
Education:
	(Last Grade Completed)
Registered voter?	Yes No
If Yes, which Party?
	Democrat, Republican, Independent...
How many children under the age of 18 in your household?

Favorite Radio Stations:
Total Annual Household Income:
Do you Gamble?	Yes No
If Yes, do you play?	3 reels 5 reels Video Poker
	(Check all that apply.)
Email Address:

Please list any friends, family or Co-workers and their telephone numbers who may be interested in participating in panels:
Name:	Phone #:
Name:	Phone #:
Name:	Phone #: