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Name: *	Last First	Date of Birth: *	mm/dd/yyyy
Company Name: *		Company Fax #:
Work Phone: *		Work City:
Home Phone:		Home City:

Job Title: *

Title

Department: *

Dept

Industry: *

Select below... Airline/Hotel/Travel Art/Literature/Entertainment Auto/Oil Building: Unspicified Building: Contractors Building: Electric Building: Plumbers Building: Trades Cleaning Products Clothing Communication Not Utility Computer/Software/Etc. Cosmetic/Beauty/Hair Dres. Education Electronics Finance: Unspecified Finance: Accountants Finance: Banking Finance: Insurance/Stock Finance: Real Estate Food Liquor/Soft Drinks Media Medical: Unspecified Medical: Dental Medical: Doctors Medical: Nurses Medical: Pharmacy Medical: Technicians Other Paper Products Service: Unspecified Service: Firemen Service: Government Service: Military Service: Police Tobacco Utilities: Unspecified Utilities: PG&E Utilities: Telephone Legal Printing/Publishing Retail: General Unspecific Manufacturing: Other Transportation/Shipping Aerospace Advertising/Market Research Chemicals/Biotech Wholesale Architure Public Relations

Number of Company Employees (estimates are good enough)?

# In Department *

# at Location

Total For Company *

Title Of Person You report to?
Email Address:

Gender? * Male Female RACE? Select one below... Asian African American Caucasian Hispanic Native American Pacific Islander Other Marital status? Select one below... Married Single Divorced Widowed Domestic Partner Highest level of education? Select one below... Less Than High School High School Graduate Some College AS or AA BA or BS Graduate School Children (Gender & DOB) Male Female Male Female Male Female Male Female

What is the range of your individual income? Select one below... Under $30K $30K to $50K $50K to $75K $75K to $100K $100K to $150K Over $150K What is the range of your household income? Select one below... Under $30K $30K to $50K $50K to $75K $75K to $100K $100K to $150K over $150K Please Indicate the type of investments you have? Select all that apply... Stocks/Bonds Mutual Funds IRA's 401K What type of Investment Services do you utilize? Select all that apply... Discount Brokers Full Service Broker Mutual Fund Co. Bank Financial Planner On Line Trading

Business trip(s) per year? Select one below... None 1 to 4 Times Per Year 5 to 9 Times Per Year Over 10 Times Per Year Indicate the types of computers at work? Select all that apply... Macintosh Intel Inside Laptop Operating System(s) used at work, (if you know)? Select all that apply MacIntosh UNIX/Linux Microsoft Other Networked? Yes No TELECOMMUTE? Yes No

Please Indicate the type of your computer at Home? Select all that apply... MAC Intel Inside PC USAGE INFO? Select all that apply... On line Purchasing On Line Banking Email Games Record Keeping Taxes Web Surfing Internet Connection Select one below... Dial Up DSL Broad Band / Cable Availability time? Select one below... Available days Available evenings only Both Availability Areas? Select one below... San Francisco Only San Mateo Other Bay Areas Locations No San Francisco Groups

Indicate The Bank(s) your Company Utilizes (If you know).

American_Savings_Bank Bank_of_America Bank_of_California Bank_of_San_Francisco Bank_of_The_Orient Bank_of_The_West Bay_View_Federal_Bank Borel_Bank_&_Trust_Co. California_Federal_Bank California_Savings_&_Loan Citibank-Citicorp Coast_Federal_Bank Commercial_Bank_of_S.F. Continentl_Savings Credit_Union Eureka_Bank Fed._Reserve_Bank_of_S.F. First_Commercial_Bank First_National_Bank First_Nationwide Gateway_Bank Glendale_Federal_Bank Golden_Gate_Bank Great_Western_bank Home_Federal_Bank Home_Savings_of_America International_Bank_of_Calif. Liberty_Bank Pacific_Bank Pan_American_Savings_Bank Redwood_Bank Sacramento_Savings_&_Loan Sanwa_Bank_of_Calif. San_Francisco_Federal Sequoia_National_Bank Sumitomo_Bank_of_Calif. Union_Bank United_Savings_Bank Wells_Fargo_Bank World_Savings_&_Loan_Assn Washington_Mutual Other

Please estimate the value of Household Liquid Assets (all assets minus Real Estate)?

Select below... Less than $99K $100K to $299K $300K to $499K $500K to $699K $700K to $999K Over $1 million

IF your Company provides Medical Insurance, Please indicate the provider?

Select below... KAISER BLUE CROSS PRUDENTIAL AETNA FOUNDATION HEALTH OMNI HEALTHCARE PRO ALLIANCE BLUE SHIELD PACIFICARE TAKE CARE HEALTH NET MEDI-CARE MEDI-CAID PRUCARE MEDI-CAL CIGNA SECURE HORIZONS UNITED HEALTH LIFEGUARD RETAIL CLERKS TEAMSTERS MAXICARE GUARDIAN Other

Primary Automobile:

Year 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Make JEEP PLYMOUTH CHARADE FORD LINCOLN MERCURY MERKUR BUICK CADILLAC CHEVROLET/GMC RESERVED OLDSMOBILE PONTIAC TRUCK HONDA HYUNDAI ISUZU JAGUAR MAZDA MERCEDES-BENZ MITSUBISHI NISSAN PORSCHE PEUGOT LAND ROVER SAAB STERLING SUBARU SUZUKI TOYOTA VOLKSWAGEN VOLVO YUGO RESERVED RESERVED LEXUS INFINITI SATURN KIA HUMMER MINI ACURA ALFA ROMEO AUDI BERTONE BMW RESERVED CHRYSLER DODGE EAGLE DAEWOO

Model (Optional)

Type of Purchase New Used Leased

Have you or anyone in your household ever participated in a research project at Ecker Consumer Research?  If yes, who   and when?