KW Research Contact: Karen Cachia Phone: (03) 9749 8199 Email: karencachia@kwresearch.com.au Get Paid Cash Incentives for your Opinion and Influence the decisions of companies about their products and services. Incentives for Market Research are very rewarding with the incentive usually being between $40 and $100 depending on the group length and/or subject matter. All information you provide to us is strictly confidential and only used for Market Research Purposes.   Web Registration Form This Research Form  should be filled out by any person interested in attending group discussions or if you wish to update your current details  - Australia Wide Please answer all questions by marking the box next to the statement which best applies to you or where required, by entering your answers in the spaces supplied. 1. Surname : 2. Firstname :     Title: Miss Ms Mr Mrs Dr   Add/Update Information ? Add a new registration, so fill-in all the info. below Update a previous registration, so only enter changed info. below 3. Address : Suburb : Postcode :    Region: VIC - Melbourne VIC - Ballarat VIC - Bendigo VIC - Geelong VIC - Gippsland VIC - Horsham VIC - Mildura VIC - Shepparton VIC - Warrnambool VIC – Wodonga/Albury NSW - Sydney NSW – Sydney West NSW – Albury/Wodonga NSW – Central Coast NSW – Newcastle/Hunter NSW – North Coast option value="NSW-RIVER">NSW - Riverina NSW – South Coast NSW – Wollongong ACT – Canberra QLD - Brisbane QLD – Cairns QLD – Gold Coast QLD – Sunshine Coast SA – Adelaide WA – Perth TAS – Hobart TAS – Launceston State: ACT NSW Queensland Victoria SA Tasmania WA 4. Telephone - Home : 5. Telephone - Work : 6. Telephone - Mobile :    Mobile Provider:  AAPT B OPTUS PRIMUS OTHER TELSTRA THREE VIRGIN VODAFONE Mobile Plan :      Capped Contract Pre-Paid Work 7. 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What credit cards, do you have (mark whichever apply) : AMERICAN DINERS STORE CARD VISA MASTERCARD OTHER     AMERICAN DINERS STORE CARD VISA MASTERCARD OTHER AMEX DINERS STORE CARD VISA MASTERCARD OTHERS     AMEX DINERS STORE CARD VISA MASTERCARD OTHERS Main Bank/Financial Institute.: AMP ANZ Bank of Adelaide Bank Of Qld Bank Of Melbourne Bankwest Bendigo Citibank Commonwealth Credit Uniion Heritage HSBC Bank ING MECU Members Equity National Rabo Bank St George Suncorp Metway Westpac Wizard Other Income of the entire household belong (before tax)?  : Under $30,000 per year 30,000 - $39,999 per year 40,000 - $59,999 per year 60,000 - $79,999 per year 80,000 - $99,999 per year $100,000   or more per year ... 13. These questions relate to your primary car: MAKE (ie. Holden) : ALFA AUDI BMW CHRYSLER CITROEN DAEWOO DAIHATSU DATSUN EUNOS FORD HOLDEN HONDA HYUNDAI JAGUAR JEEP KIA LANDROVER LEXUS MAZDA MERCEDES MITSUBISHI NISSAN PEUGEOT PORSCHE PROTON RENAULT SAAB SEAT SUBARU SUZUKI TOYOTA VOLKSWAGON VOLVO OTHER MODEL (ie. Commodore) : Year of Manufacturer : Car insured with : ... 14. Do you have pets:  Cat    Dog    Bird    Rabbit     Horse    Fish    Mice   Chooks  Guinea Pig        Farm Animals   Other    15. If you have children, please choose boy or girl and their Year of births:    Child BOY, year of birth (YYYY):    Child BOY, year of birth (YYYY):    Child BOY, year of birth (YYYY):    Child GIRL, year of birth (YYYY):    Child GIRL, year of birth (YYYY):    Child GIRL, year of birth (YYYY):     Are they interested in attending Groups ? :  YES NO ... 16. What is your current marital status :   DE FACTO DIVORCED ENGAGED MARRIED SEPERATED SINGLE WIDOWED OTHER ... 17. Do you smoke cigarettes :   NO - a non-smoker Alpine Any B & H Banks Cartier Chesterfield Cigars Drum Dunhill Holiday Horizon Kent Longbeach Marlboro Menthol Peterjack Peterstuy Portroyal Rollons StMoritz Winfield   18. Do you have Pay TV:   YES NO   19. Current Housing Arrangement :   Board Free Accomodation Mortgage Owned Rent Other    Insured with:  20. Do you have Private Health Insurance :   NO - do not have it ANA Aus Unity Army Health BUPA CBHS Commonweal Defence GMF GMHBA Gov Employee HCF IOOF IOR Latrobe Manchester MBF Medibank NIR NIB NSW Teachers OSHC RACV St Lukes Trans Benefits Other   21. Preferred Supermarkets:   Aldi Any Bi-Lo Coles Coles Online IGA Market Not Quite Rite Safeway Sims Other   Aldi Any Bi-Lo Coles Coles Online IGA Market Not Quite Rite Safeway Sims Other 22. What Radio station(s) do you listen to :   3AW 3MBS FM 3MMM 3MP ABC Bay FM Fox FM Gold FM Joy FM K Rock Light FM Magic Mega FM Mix FM Nova FM SEN Triple J Triple R Vega FM Sport 927   3AW 3MBS FM 3MMM 3MP ABC Bay FM Fox FM Gold FM Joy FM K Rock Light FM Magic 693 Mega FM Mix FM Nova FM SEN Triple J Triple R Vega FM Sport 927 OTHER 23. Current Reward Programmes   Fly Buys      Frequent Flyers   Others 24. What is your Nationality:   ABORIGINAL ARABIC AUSTRIAN AUSTRALIAN BOSNIAN BRITISH CANADIAN CHILEON CHINESE COLUMBIAN CROATION CZECH DUTCH EGYPTIAN FRENCH GERMAN GREEK HUNGARIAN INDIAN INDONESIAN IRAQI IRISH ISRAELI ITALIAN KENYAN LEBANESE MACEDONIAN MALTESE MAURITIAN MALAYSIAN NEPALI NEW ZEALAND NORWEGIAN PAKASTANI PHILIPPINO POLONESIAN POLISH RUSSIAN SINGAPORE SRI LANKIN SWEDISH SCOTTISH SLOVAKIAN SOUTH AFRICAN SOUTH AMERICAN SPANISH SWISS THAILAND TURKISH UKRANIAN VIETNAMESE YUGOSLAV OTHER 25. Do you receive any of the following Centrelink payments:   Family Tax Benefit (A) Family Tax Benefit (B) Sickness Allowance Youth Allowance Austudy Disability support pension Newstart Allowance Double orphan allowance Age Pension Carer Allowance Widow allowance Mature Age Allowance Abstudy Other   Family Tax Benefit (A) Family Tax Benefit (B) Sickness Allowance Youth Allowance Austudy Disability support pension Newstart Allowance Double orphan allowance Age Pension Carer Allowance Widow allowance Mature Age Allowance Abstudy Other PLEASE make sure you answer the following Questions: 26. Hear about us from:   Advertisement Flyer Friend Google Gumtree Family Member (Mum,Dad,Husband) Relative Web Serach Work Mate      Friend's Name: 27. Have you ever taken part in Market Research groups?:   YES NO     Registered with other Recruiting Organisations ?:   YES NO   Thank you   Click   to email a link of this page to a friend     Design:  Copyright © 2005-2013