Smith Research - Oakbrook, Chicago and Deerfield, IL

Do you prefer iced tea or hot tea? What flavor of herbal tea do you like best?

When you become a Smith Research participant, your answers to these types of questions help determine what products you’ll see on store shelves in the future.

Smith Research has been collecting consumers’ opinions about new products for more than 40 years. With locations in Oak Brook, Chicago and Deerfield, we’re easily accessible throughout the Chicago metropolitan area — and our participants get paid for their opinions.

We don’t sell information about you to other companies, so you won’t get inundated with junk mail or phone calls if you participate. In fact, we don’t sell anything to anyone — not even you. We just listen.

Manufacturers used consumer input to develop cordless irons and flip phones. You can help them decide what to do next.

To register as a participant, please complete this short form:

About you:
* Required information
First name:*
Last name:*
Gender:	Male Female
Age:*
Date of birth:*	(mm/dd/yyyy)
(Please don't be shy. We won't share ANY of your information with anyone.)
Address line 1: *
Address line 2:
City:* State:* Zip code:*
Is this address a/an:
Do you:
E-mail address:*
Home phone:*
Cell phone:
Work phone:	Ext.:
Work Fax:

Marital status:
Education:

Auto
	Year	Make (e.g., Ford)	Model: (e.g., Taurus)
1.
2.
3.
4.

Children (Please enter information for up to three children)

Please provide this information as completely as possible if you would like to be considered for participating in Family-Type studies with your children.

Child 1
First Name:	Last Name:	Birth Date: (mm/dd/yyyy)

Gender: Male Female
Does this child have any food allergies? Yes No
If your child is of a different ethnicity than yourself, what ethnicity are they?

Does this child live full-time in your home? Yes No

Child 2
First Name:	Last Name:	Birth Date: (mm/dd/yyyy)

Gender: Male Female
Does this child have any food allergies? Yes No
If your child is of a different ethnicity than yourself, what ethnicity are they?

Does this child live full-time in your home? Yes No

Child 3
First Name:	Last Name:	Birth Date: (mm/dd/yyyy)

Gender: Male Female
Does this child have any food allergies? Yes No
If your child is of a different ethnicity than yourself, what ethnicity are they?

Does this child live full-time in your home? Yes No

Employment Information
Employment status:
Occupation:
Your title:
Company name:


In what industry is your employer?

Spouse/Significant Other Employment Information

Occupation:
Title:
Company name:


In what industry is his/her employer?

Total annual household income:


Health Information
Do you have any dietary restrictions? Yes No
If yes, please list:
Do you have any chronic health conditions, including, but not limited to, high blood pressure, diabetes, asthma or allergies? Yes No
If yes, please list:
Prescriptions taken:
Diabetes: Type 1 Type 2 Insulin Oral meds


Technology Information
Is your home computer a PC or Mac (or both)? Mac PC
Who is your cell phone provider?
What is the brand of your cell phone?
Is your cell phone a smart phone? Yes No


Miscellaneous
Do you drink alcoholic beverages? Yes No
Do you or anyone in your household smoke? Yes No

When complete, click the Submit Questionnaire button. Remember, all your information is strictly confidential and will only be used to assist our interviewers in selecting you for the appropriate focus groups. Thank you in advance for your participation.

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