Shopper Questionnaire
* Required Field
WHO ARE YOU?
*NAME:

      (First, MI, Last)
*GENDER:

*BIRTHDATE: / /
*MARITAL STATUS: 
*HOUSEHOLD INCOME?:  
*ETHNIC BACKGROUND?: 
WHERE ARE YOU FROM?
HOME ADDRESS:
*STREET/APT:
 
*CITY:  
*STATE / PROVINCE:
*COUNTRY:
*ZIP / POSTCODE:
MAILING ADDRESS (CANNOT BE A P.O. BOX):
> My mailing address is the same as above. <
STREET/APT:
 
CITY:
STATE / PROVINCE:
ZIP / POSTCODE:
HOW CAN WE REACH YOU?
*HOME PHONE#: (   )   - 
WORK PHONE#: (   )   -       EXTENSION:  
CELL PHONE#: (   )   - 
FAX#: (   )   - 
*E-MAIL ADDRESS:
*CONFIRM E-MAIL ADDRESS:
HOW DID YOU HEAR ABOUT TES/RAPID CHEK?
*
IF FROM A SEARCH ENGINE, WHICH PARTICULAR ONE AND WHAT WORD DID YOU TYPE IN FOR SEARCH? ( AOL, Excite, Infoseek, Yahoo, ect.)
IF OTHER,
LIST NEIGHBORING CITIES WHERE YOU WOULD ACCEPT ASSIGNMENTS:

*1.

2.

3.
4.
5.
6.

 

3619 Motor Ave., Suite 300, Los Angeles, CA 90034
(310) 840-5800