Field Recruiting

Field Recruiting is a Market Research Company specializing in the recruiting of respondents to participate in focus groups, where individual opinions are shared about consumer products and services.

Your personal information provided is held in the strictest confidence and used solely for the purpose of placing you in the appropriate study groups. Absolutely no sales or solicitation of any kind is conducted.

If you are interested in participating in Focus Group studies where you will be compensated with a cash incentive for your valuable opinions and time, please fill out the form below.

Referred By:
First Name:
Last Name:
Gender:
Date of Birth:
Month:
Day:
Year:
Current Age:
Email #1:
Email #2:
Res #:
Cell #:
Bus #:
Street Address:
Unit #:
Buzz Code:
Postal Code:
City of Residence (ex. Ajax, Richmond Hill):
Major Intersection of Residence:
&
Major Intersection of Business:
&
Marital Status:
Occupation:
Type of Industry:
Spouse Occupation:
Type of Industry:
Student:
Retired:
Children at Home:
Children not at Home:
# of People in Household
Education:
Country of origin:
City of origin:
Year arrived in Canada:
Year arrived in Ontario:
Ethnic Background:
Driver's License:
Do you have a vehicle:
Are you a smoker:

Have you ever suffered from any of the following?

Allergies - Food
Allergies - Seasonal
Allergies - Year Round
Arthritis
Asthma
Cancer (breast)
Cancer (prostate)
Cancer (other)
Crohns
Diabetes
ED
Genital Herpes
Heart Disease
High Cholesterol
HIV/AIDS
IBD
Macular Degeneration
Psoriasis/Eczema
Other:  


Has anyone in your immediate family ever suffered from any of the following?

Allergies - Food
Allergies - Seasonal
Allergies - Year Round
Arthritis
Asthma
Cancer (breast)
Cancer (prostate)
Cancer (other)
Crohns
Diabetes
ED
Genital Herpes
Heart Disease
High Cholesterol
HIV/AIDS
IBD
Macular Degeneration
Psoriasis/Eczema
Other:  

Do you have any pets:
Type of Dweller:
Main Financial Institution:
Other Financial Institution:
Total Household Income:
Cellular Provider:
Type of Cell Phone:
Devices you own:




Other Device:
Social Networks:
Facebook:     Twitter:     MySpace     LinkedIn
Eye Wear:
Glasses:     Contact Lenses: