Survey

 
Fields marked with * are required for registration, however the more information you are able to provide the better we are able to find research that will be of interest to you. We do realize this is alot of information; please don't give more information than you're comfortable sharing. We will never, in any way, sell our lists. Ever. More information about Plaza Research and our locations can be found on our corporate website: www.plazaresearch.com.

Find us on Facebook: www.facebook.com/plazaresearch
   
Please enter your e-mail address and a new password below. You can use this information to log-on to the survey at a later date to modify your answers.

E-Mail Address *
Password *

How Did You Hear About Us *
First Name *
Last Name *
Age
Birth Date * (xx/xx/xxxx)
Gender * Female    Male
Ethnicity *
Marital Status *

Home Address
City *
State *
Zip *
County *

Home Phone * (xxx-xxx-xxxx)
Business Phone (xxx-xxx-xxxx)
Cell Phone * (xxx-xxx-xxxx)
If you do not have a cell phone, please enter 999-999-9999
Cell Provider
Cell Payment  Contract    Pre-Paid    Other
Preferred Phone  Home    Business    Cell   

Education

 
Highest Education Level Completed
State College Attended
College Attended
College Major

Electronics

 
Digital Video Recorder  Yes     No
3D Television  Yes    No
Blu-Ray  Yes    No
Cable TV Provider
Camera-Point and Shoot  Yes    No
Camera - DSLR  Yes    No
HD Television  Yes    No
Type of Cell Phone
Type of Computer at Home Mac    PC
Video Game System at Home  XBOX360
 PS3
 Kinect
 Wii
 Other
Tablet - IPad  Yes    No
Tablet - Blackberry  Yes    No
Tablet-Other  Yes    No

Employment

 
Company Name
Industry
Occupation
Role in Company
Employment Status
# of Employees
Revenue Level

Financial

 
Checking Account  Yes    No
Checking Account Provider
Savings Account  Yes    No
Savings Account Provider
Credit Cards  Yes    No
Investment Account  Yes    No
Amount in Liquid Assets

Household

 
Number in Household
Child 1 Name
Child 1 Birthday (xx/xx/xxxx)
Child 1 Gender  Male    Female
Child 1 Ethnicity
Child 2 Name
Child 2 Birthday (xx/xx/xxxx)
Child 2 Gender  Male    Female
Child 2 Ethnicity
Child 3 Name
Child 3 Birthday (xx/xx/xxxx)
Child 3 Gender  Male    Female
Child 3 Ethnicity
Child 4 Name
Child 4 Birthday (xx/xx/xxxx)
Child 4 Gender  Male    Female
Child 4 Ethnicity
Household Internet Provider
Home  Own    Rent
Pool  Yes    No
Solar Power  Yes    No    Interest
Spa  Yes    No
Type of Flooring
Type of Home

Lifestyle

 
Alcohol
Tobacco Dip User  Yes    No
Tobacco Usage  SNUS
 Chewing Tobacco
 Cigars
 Cigarettes
Smoker  Yes    No
Brand of Cigarettes
Length of Cigarettes
Type of Cigarettes
Gym Membership  Yes    No

Medical

 
Check all that apply  
 Acid Reflux Cancer - Colon Cystic Fibrosis Heart Disease Osteoarthritis
ADHD Cancer - Other Dentures Hemophilia Osteoporosis
Allergies Cancer - Leukemia Depression Hepatitis A Overactive Bladder
Alzheimers Cancer - Ovarian Diabetes Type 1 Hepatitis B Parkinsons
Arthritis Cancer - Pancreatic Diabetes Type 2 Hepatitis C Primary Immune Deficiency (PID)
Asthma Cancer - Prostate Dietary Restrictions Lupus Psoriasis
Atrial Fibrillation Cancer - Skin Eczema Herpes Zoster Psoriatic Arthritis
Autism Cancer - Thyroid Enlarged Prostate High Blood Pressure Rheumatoid Arthritis
Back Problems Cataracts Epilepsy High Cholesterol Rheumatoid Arthritis
BiPolar Celiac Disease Fragile X HIV/AIDS Sleep Disorders
Cancer - Bladder Contact Lense Gastic Bypass Hormone Issues Stroke
Cancer - Endometria COPD Glasses Lasik Surgery Surgeries
Cancer - Brain Coumadin Users Gout MS Testosterone Issues
Cancer - Breast Crohns Hearing Aid Non Hodgkins Lymphoma Thyroid
         
Past Surgery Locations
(Check all that apply)
       
         
Brain Back Legs Feet  
Facial Digestive Reproductive    
Chest Arms Hands    

Military

 
Current Military Service?  Yes    No
Current Military Branch
Past Military Service?  Yes    No
Past Military Branch

Personal

 
Car Insurance  Yes    No
Car Insurance Provider
Caregiver for Anyone?  Yes    No
Health Insurance  Yes    No
Health Insurance Provider
Life Insurance  Yes    No
Life Insurance Provider
Household Income
Home Insurance  Yes    No
Home Insurance Provider
Personal Income
Place of Birth
Primary Language
Sexual Orientation
Speak Spanish?  Yes    No
   
Languages Spoken in Household (check all that apply)
English Spanish
French German
Italian Arabic
Chinese Japanese
Korean Other
   
Languages Spoken Outside of Household (check all that apply)
English Spanish
French German
Italian Arabic
Chinese Japanese
Korean Other
   
   

Political

 
Party Affiliations (check all that apply)  
Democrat Independent
Republican Tea Party
   
Active Voter?  Yes    No
Registered to Vote?  Yes    No

Religion

 
Religious Affiliations (check all that apply)  
Baptist Christian
Catholilc Jewish
Muslim Protestant
Other  
   

Vehicle Ownership

 
Own ATV  Yes    No
Own Boat  Yes    No
Own Motorcycle  Yes    No
Car 1 Make
Car 1 Model
Car 1 Year
Car 2 Make
Car 2 Model
Car 2 Year
Car 3 Make
Car 3 Model
Car 3 Year

Pets

 
Dogs  1     2     3     4     5+
Cats  1     2     3     4     5+
Rabbits  1     2     3     4     5+
Reptiles  1     2     3     4     5+
Birds  1     2     3     4     5+
Other Animals  1     2     3     4     5+