Panel Registration
Title: 
   

First Name: * 
     

Last Name: *
   
 
Address 1: 


Address :


City: 
    

 Province/State:
 

Postal Code/Zip Code:


Country:


E-Mail :  * 
 
   

Alternate E-Mail: 


Phone Number (###-###-####):  *
   

Cell Phone:


Work Phone:


Fax Number:


Preferred method of Contact:
Gender: *   


BirthDay:
Month:      Day:         Year:

Marital Status:
Highest Level of Education:
Your Residence:

Do you have children under the age of 18 living at home:    
 
Yes
No


Employment Status:
Employment Type:
Occupation:


Industry:


We often do online studies, interviews, and focus groups on medical conditions. Do you have any medical or physical conditions you would be comfortable discussing?
Yes
No     



Do you smoke:
Yes
No
     

Do you regularly listen to the radio:
Yes
No


Do you have pets:
Yes
No



Do you have any food/beverage allergies or sensitivities that prevent you from consuming certain foods? This includes dairy, chocolate, lactose, nuts. *
If Yes, Please specify:


Do you own a vehicle:
Yes
No


Where were you born:



How long have you lived in Canada?

Ethnicity:















Household income (before Taxes):








Where did you hear about us:










If you would like to pass along  any additional information about yourself or brief comments about this reisttration process, please enter them here. If you would like us to respond, please send us an e-mail instead.


Please submit your information. An e-mail will be sent to the first e-mail address that you provided. You must confirm your registration with the instructions provided in this e-mail in order to be added to our secure list of panelists.