GEMS Form

Ruth Nelson Research Services
2149 South Grape Street
Denver, CO 80222-5203
(303) 758-6424
Fax: (303) 756-6467

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Cell Phone:

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First Name *

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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 *

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List All Children Under 18 in Your Home: *

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Child Name:

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Child Name:

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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

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