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ABOUT YOU* Denotes mandatory field Title*please selectMrMrsMissMsDr Date of Birth* -- 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th 13th 14th 15th 16th 17th 18th 19th 20th 21st 22nd 23rd 24th 25th 26th 27th 28th 29th 30th 31st -- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec -- 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 First Name*Surname*Gender*please selectMaleFemale Marital Status*please selectSingleMarriedDivorcedSeperatedWidowed Address Line 1*Home Tel Number*Address Line 2Work Tel NumberTown*Mobile Tel Number*CountyYour ethnic backgroundplease selectWhite BritishWhite OtherBlack AfricanBlack CaribbeanBlack OtherIndianChinesePakistaniBangladeshEuropeanOther Post Code* Email Private*note. you will recieve an email confirmation at this address.Email WorkHave you been to College/University/Other further training*Yes No No. Children under 16 in your householdAre you the main income earner*Yes No If not born in UK, how long have you lived here*Are you the head of householdYesNoPlease specify your educational/degree/professional qualifications* ABOUT YOUR WORK* Denotes mandatory field Do you work*Yes No Your Job Title*Are you self employed*Yes No If you are self employed, do you employ others - if so, how manyWhat industry are you in*Job title of partnerDo you have a home office*Yes No ABOUT YOUR VEHICLES* Denotes mandatory field Vehicle 1 MakeVehicle 1 ModelVehicle 1 Typeplease select2 Door3 Door4 Door5 Door Estate4 x 4SUVMPVScooterMotorcycleVan Vehicle 1 Yearplease select200720062005200420032002200120001999 or older Vehicle 1 Purchasedplease selectNewUsedLeasedCompany Car Vehicle 2 MakeVehicle 2 ModelVehicle 2 Typeplease select2 Door3 Door4 Door5 Door Estate4 x 4SUVMPVScooterMotorcycleVan Vehicle 2 Yearplease select200720062005200420032002200120001999 or older Vehicle 2 Purchasedplease selectNewUsedLeasedCompany Car Vehicle 3 MakeVehicle 3 ModelVehicle 3 Typeplease select2 Door3 Door4 Door5 Door Estate4 x 4SUVMPVScooterMotorcycleVan Vehicle 3 Yearplease select200720062005200420032002200120001999 or older Vehicle 3 Purchasedplease selectNewUsedLeasedCompany Car GENERAL* Denotes mandatory field Which of the following do you own or use? Virgin MediaSKYHDTVFreeviewComputerLaptopApple MacIPodMP3PDABroadband InternetX BoxPSPPlay StationDVD WriterScannerColour PrinterBlu-RayDigital CameraDigital Video CameraSkype (or similar VOIP)GlassesContact LensesNetbookiPadFreesatWii ABOUT YOUR HOUSEHOLD* Denotes mandatory field Child 1 AgeChild 2 AgeChild 3 AgeChild 4 Age FINANCIAL SERVICES* Denotes mandatory field Who do you bank with*please selectBarclaysLloyds/TSBNatwestHSBCAbbeyHalifaxRBSOther Any others please listDo you bank online*Yes No If yes which bankDo you have Credit Cards*Yes No If yes, which bank or organisation issued itDo you have Private Health Insurance*Yes No If yes, who with YOUR MOBILE PHONE* Denotes mandatory field What make and model is your current mobile(s)How many mobiles have you previously ownedAre you on Contract or Pay As You GoWho is your mobile service providerDo you use the internet services on your mobileYesNoDo you use the camera on your mobileYesNo FOCUS GROUPS* Denotes mandatory field Are you registered with any other recruiters for Market research*Yes No If yes, who withHave you attended a focus group within the last 6 months*Yes No DECLARATION - please read before registering I hereby give permission for this information to be held confidentially and securely by Market Research Recruitment in accordance with the Data Protection Act 1998, for the sole purpose of inviting me to participate in market research. I understand that I have the right to decline or withdraw at any time and to have my details deleted from the database. I agree to be audio taped and video recorded for research purposes at the venue. Upon agreeing to take part in a focus group or one-to-one interview, I will make every effort to attend and to be there on time. Should circumstances out of my control arise, where I cannot attend a focus group or interview, I will notify Market Research Recruitment as quickly as possible, and where possible with at least 24 hours notice of non-attendance. I have read and agree to the above terms and conditions. MRS Code of Conduct ensures that the information you give us is confidential, and will not be passed onto another company, and that you will not receive sales or direct mail as a result of registering with us
