GEMS Form

Ruth Nelson Research Services
10220 North 31st. Avenue
Suite 122
Phoenix, AZ 85051-9562
Phone: 602-944-8001
Fax: 602-944-0130

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Home Phone:

Cell Phone:

WorkPhone:

First Name *

Last Name *

Gender *

Date of Birth *

Ethnicity *

Marital Status *

Education *

Employment Status *

Type of Job if Employed:

Residence *

Do you *

Do you consider yourself *

Total Annual Household Income *

Do You Drink Beer? *

Favorite Brand of Beer:

Do You Own/Have: *

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Do You, or Anyone in your Household, Have: *

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Including Yourself, How Many People Live in Your Household? *

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Do You have any Pets? *

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Other Pet:

Do You Listen to the Radio? *

Type of Music played on Favorite Station

Address *

City *

Zip *

County *

List All Children Under 18 in Your Home: *

OR No Children

Child Name:

Gender

Date of Birth:

Child Name:

Gender

Date of Birth:

Child Name:

Gender

Date of Birth:

Child Name:

Gender

Date of Birth:

Do You Smoke Cigarettes? *

Do You Own a Pool? *

Do You Own A Personal Computer? *

Do You Have Internet Access? *

E-Mail Address: *

Do You Ski? *

Do You Snowboard? *

List the 2 Primary Vehicles for Your Household: *

OR No Vehicles

Make:

Model:

Year:

Make:

Model:

Year:


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