Ecker Consumer Research, INC.
Please Note:
Ecker & Associates respects your privacy; all information provided is confidential and will
never be given out to any other agency or company.  This information will be used exclusively by
Ecker & Associates for finding appropriate respondents for market research studies and related projects. 

Due to potential conflicts of interest, we cannot use Respondents who work in the Advertising or Market Research Industry.

To Respondents living outside the
San Francisco Bay Area:
Thank You for your interest.
However, we do not use respondents living outside the San Francisco Bay Area.

Feel free to call us at (650) 871-6800 if you have any questions.
1. About Yourself
Ecker wants to know all about you. So please, enter all the information you can.
This will help us get you into a group that you will qualify for. Fitting respondents
to group subjects that they have "knowledge of" or an "interest in" is what makes
Ecker the best at recruiting focus groups.
2. About Your Spouse
If you would like for Ecker to have your Spouse's information on file, there are
spaces provided for spousal information.  All spousal information is optional
(not everyone is married). 
* Required Entries
Referred By:
Name: *
First *
Last * 		Date of Birth: *
(Ex: mm/dd/yyyy)
Respondents must be 18 or older.
Address: *
Street Address:*
City, St Zip: *

City:*
State:*
Zip: *
Occupation: (Select from Menu)
 		Industry: *
(Select from Menu)
Job Title:
Your Job Title

Comments:
Example: I wish to contacted by Cell Phone only.



* * * * * * * * * * * * * * * * * * * * S P O U S E * * * * * * * * * * * * * * * * * * * *
Spouse Name:
Spouse First Name
Spouse Last Name 		Spouse DOB:
(Ex: mm/dd/yyyy)
Respondents must be 18 or older.
Spouse Occupation:
(Select from Menu)
 		Spouse Industry:
(Select from Menu)
Job Title:
Spouse Job Title

Comment:
Example: Do Not Call at work.




Phones


 		Home PH# *
Ex: 650-871-6800 		Work PH#
Ex: 650-871-6800 		Cell PH#
Ex: 650-871-6800 		Spouse Work PH#
Ex: 650-871-6800 		Spouse Cell PH#
Ex: 650-871-6800
Gender? *
You Spouse
Male
Female

Type Of Home?

Own
Rent
Live With Parents
Availability Time of Day *
You Spouse
Days
Evenings

Availability Area  *
No San Francisco Groups
San Francisco only
San Mateo Only
All Bay Area Locations
How many persons reside in your household (include children)?

1 5
2 6
3 7
4 Over 7

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

(Select One From Menu)
Less than $99K
$100K to $299K
$300K to $499K
$500K to $699K
$700K to $999K
Over $1 million

Email Address:

You
Spouse
What is your marital status? *

(Select One From Menu)
Married
Single
Divorced / Widowed
Domestic Partner


Ethnic Heritage?

You Spouse
Asian
African American
Caucasian
Filipino
Hispanic
Native American
Other

Describe current employment.

You Spouse
Full time
Part time
Retired
House Wife
Student
Unemployed


Do you require a special diet?

(Select All that Apply)
You Spouse
Low Calorie
Low Cholesterol
Vegetarian
Other (Specify)
You

Spouse


Alcohol (Weekly)?

(Select All That Apply)
You Spouse
Beer
Wine
Liquors
Gin
Vodka
Scotch
Bourbon
Other
What is your Individual income?

You Spouse
Under $20K
$20K to $30K
$30K to $40K
$40K to $50K
$50K to $80K
$80K to $100K
Over $100K

Highest Level of Education Completed:

You Spouse
Less than High School
High School Grad
Some College
AA / AS
BA / BS
MA / MS or PHD

Voter Registration?

You Spouse
Independent
Democrat
Republican
Other


Special Interest items, select those you/spouse use or own.

You/Spouse
Boat
Digital Camera
Contact Lenses
HDTV
Global Pos. Sys. (GPS)
Housekeeper/Cleaning Service
Nintendo, XBox, etc.

What Credit cards do you/spouse use?

You/Spouse
American Express
Master Card
Visa
Discover Card

Do you or your spouse suffer from any of the following medical conditions?

Ecker & Assoc. regards this information as extremely sensitive and guarantees it's confidentiality.

You/Spouse
Diabetes Type I
Diabetes Type II
Asthma
Heart Disease
Depression
Cancer
Hepatitis
Herpes
What is your household income?

(Select From Menu)
Under $25K
$25K to $45K
$45K to $55K
$55K to $75K
$75K to $100K
$100K to $150K
Over $150K

What type of investments does your household have?

(Select All That Apply)
Stocks/Bonds/Mutual Funds
Full Service Broker
Discount Broker
Online Trading
Other


Have you traveled to any of the areas listed below?

(Select All That Apply.)
Africa
Asia
Australia
Europe
South America
Other

Have you gone on a cruise?

(Select one From Menu.)



Do you have either a cat or dog?

Dog (s)
Cat (s)


How many times a year do You and/or Your Family Fly?

1 3 5 7+
Please indicate the DATE of Birth and gender of your children. If no children then skip this item.

Boy Girl
Date of Birth #1:

Boy Girl
Date of Birth #2:

Boy Girl
Date of Birth #3:

Boy Girl
Date of Birth #4:


Women's Dress size?

You (Select from Menu)


Spouse (Select from Menu)

Men's Pant (Waist) size?

You (Select From Menu)


Spouse (Select From Menu)



Indicate the name of your Medical Insurer and type of Policy?

Individual Group
(Select From Menu)


Individual Group
Spouse (Select From Menu)

Smokers?
(Select ONE)


Spouse (Select ONE)


* * * * * * * * * * * * * * * Radio, Hobbies & Banks * * * * * * * * * * * * * * *
AM Radio Stations:

Select No more than 3 Stations for you. If you have a spouse select 3 stations for your spouse.

Web Page listing SF Bay Area AM-Radio Stations.

If you select more than three, Only the first three (3) stations selected will be used!
You/Spouse
KABL / 960
KATV / 990
KAZA / 1290
KBLX / 1400
KCBC / 770
KCBS / 740
KDFC / 1220
KDIA / 1310
KEST / 1450
KFAX / 1100
KFRC / 610
KGO / 810
KIQI / 1010
KKSJ / 1370
You/Spouse
KLIV / 1590
KLOK / 1170
KNBR / 680
KNEW / 910
KNOB / 1510
KNTA / 1430
KOFY / 1050
KOIT / 1260
KPIX / 1550
KRRS / 1460
KSFO / 560
KSJX / 1500
KSRO / 1350
KTOB / 1490
FM Radio Stations:

Select No more than 3 Stations for yourself and 3 stations for your spouse in the space provided.

Web Page listing SF Bay Area FM-Radio Stations.

If more than 3 stations are selected only the first 3 selected will be used!
You Spouse
KI0I / 101.3
KALW / 91.7
KALX / 90.7
KARA / 105.7
KBAY / 100.3
KBGG / 104.9
KBLX / 102.9
KCRH / 89.9
KCSM / 91.1
KDFC / 102.1
KEAR / 106.9
KEZR / 106.5
KFJC / 89.7
KFOG / 104.5
KFRC / 99.7
You Spouse
KHQT / 97.7
KISS / 98.1
KITS / 105.3
KKSF / 103.7
KLCQ / 92.9
KLRS / 92.7
KLVR / 88.9
KMEL / 106.1
KOIT / 96.5
KOME / 98.5
KPFA / 94.1
KPFB / 89.3
KPOO / 89.5
KQED / 88.5
KRQR / 97.3
You Spouse
KRTY / 95.3
KSAN / 94.9
KSJO / 92.3
KSOL / 98.9
KSRI / 99.1
KSTJ / 102.7
KUFX / 94.5
KUSF / 90.3
KVHS / 90.5
KVYN / 99.3
KYCY / 93.3
KYLD / 107.7
KZBR / 95.7
KZST / 100.1
KZSU / 90.1
KZWC / 92.1
Hobbies:

Select up to 7 hobbies for yourself and 7 for your spouse.


IF You Select more than Seven (7), only the first seven will be saved.
You Spouse
Back Packing
Ball Games
Bicycling
Body Building
Bowling
Camping
Fishing/Hunting
Gardening
Golf
Gourmet_Cooking
Ice/Roller_Skating
Jazzercise/Aerobics
Jog/Run/Walk
You Spouse
Karate
Motorcycles
Photography
Tennis/Racket/Handball
Sailing
Scuba_Diving
Sewing
Snow_Skiing
Water_Skiing/Swimming
Horseback_Riding
Fitness
Dancing
Arts/Crafts
You Spouse
Reading
Music
Movies
Antiques
Coin_Collecting
Cars
Video_Games
Travel
Computers
Snow_Boarding
Pets
Shopping
BANKS


Indicate The Bank (s) that your Household uses.
American_Savings_Bank
Bank_of_America
Bank_of_CA.
Bank_of_S.F.
Bank_of_The_Orient
Bank_of_The_West
Bay_View_Fed_Bank
Borel_Bank_&_Trust_Co.
California_Fed_Bank
California_S&L
Citibank-Citicorp
Coast_Fed_Bank
Commercial_Bank_of_S.F.
Continental_Savings
Credit_Union
Eureka_Bank
Fed._Reserve_Bank_of_S.F.
First_Commercial_Bank
First_National_Bank
First_Nationwide
Gateway_Bank
Glendale_Fed_Bank
Golden_Gate_Bank
Great_Western_bank
Home_Fed_Bank
Home_Savings_of_America
International_Bank_of_CA.
Liberty
Pacific
Pan_Am_Savings
Redwood
Sacramento_S&L
Sanwa_of_CA.
San_Francisco_Fed
Sequoia_Natl
Sumitomo_of_CA.
Union
United_Savings
Wells_Fargo
World_S&L_Assn
Washington_Mutual
Other




Automobiles:
Year Make Model (optional)
1
2
3
When entering model(s) use one word "ThunderBird" not "Thunder Bird" and "Civic" not "Civic EX".
Have you or anyone in your household ever participated
in a research project at Ecker Consumer Research before?

If yes, who? and when (month/year)?