This questionnaire should be filled out by any person over 15 years of age who is
interested in attending MR groups, interviews and clinics.
Where do you live: ?
ACT
Adelaide
Brisbane
Melbourne
Northern Territory
NSW - Regional
Perth
Queensland - Regional
Victoria - Regional
Tasmania
South Australia - Regional
Sydney
Tasmania
Western Australia - Regional
* (* indictaes
required fields)
1.
First Name :
*
2.
Surname :
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 :
(optional)
Suburb:
*
Postcode :
State :
VIC
ACT
NSW
NT
QLD
SA
TAS
WA
*
4.
Telephone - Home :
(include area code)
*
Telephone - Work :
(include area code)
*
Telephone - Mobile :
*
Plan:
Under Contract (post paid)
Company Supplied
Prepaid
Mobile Provider:
3
AAPT
OPTUS
ORANGE
OTHER
TELSTRA
VIRGIN
VODAFONE
5.
Email Address :
*
* We may email you from time to time
regarding groups, enter
'OPT OUT' in the Email Address if you do not wish this to happen.
Email Check Frequency :
Hourly - read email Hourly
Daily - read email Daily
Weekly - read email Weekly
*
6.
Your Gender :
FEMALE
MALE
*
What is your marital
status :
DEFACTO
DIVORCED
MARRIED
SINGLE
WIDOW
*
Country of
birth :
ABORIGINAL
AFGHANI
AFRICIAN
ARABIC
ASIAN
AUSTRALIAN
BANGLADESH
BRITISH
CANADIAN
CHILIAN
CHINESE
CROATION
CZECH
DUTCH
EGYPTIAN
ERITREA
ETHIOPIA
FILOPINO
FRENCH
GERMAN
GREEK
HUNGARIAN
INDIAN
INDONESIAN
IRANIAN
IRAQI
IRELAND
ISRAELI
ITALIAN
JAPANESE
JEWISH
KOREAN
LEBANESE
MACEDONIAN
MALAYSIAN
MALTESE
MAURITIUS
MEXICAN
NEW ZEALANDER
NORWEGIAN
PAKASTANI
PHILIPPINE
POLISH
PORTUGESE
RUSSIAN
SAUDI
SINGAPOREAN
SLAVIC
SOMALIAN
SPANISH
SOUTH AFRICAN
SOUTH AMERICAN
SRI LANKIN
SWEDISH
THAILAND
TONGAN
TURKISH
UKRANIAN
VIETNAMESE
YUGOSLAV
OTHER
*
Date of birth :
Day (01-31) / Month (01-12) / Year (1900-) *
7.
Employee: Job Title
Employed Status :
FULL TIME
PART TIME
CASUAL
NOT WORKING
HOME DUTIES
*
Self
Employeed :
YES
NO
*
Your
occupation (ABS codes) :
Professional: ie. Doctor, dentist, solicitor, accountant
Semi-Professional: ie. Specialised technician,teacher,nurse
Skilled: ie. Qualified tradesman
Clerical: ie. Office Work,..
Retail: ie. Sales, Shop Assistant,
Apprentice / Trainee
Business Executive:
Manual Work:
House-Wife/House-Husband:
Student:
Retired/Other:
Un-Employed:
*
What
Industry Type :
ACCOUNTING
ARTS
ARCHITECT
BANK/FINANCE
CHARITY
CHILDCARE
CONSTRUCTION
CONSULTANT
COUNCIL
CUSTOMS
DESIGN
EDUCATION
ELECTRICIAN
ENGINEER
ENTERTAINMENT
FASHION
FINANCE
GOVERNMENT
HEALTHCARE
HOSPITALITY
INSURANCE
INFO. TECHNOLOGY
LEGAL
MANUFACTURING
MARKETING
MEDIA
MEDICAL PROFESSIONS
POLICE
PROPERTY
PUBLISHING
RECRUITMENT
RETAIL
SCHOOL
SECURITY
SHIPPING
SKILLED TRADE
SOCIAL WORK
TELECOMMUNICATIONS
TOURISM
TRANSPORT
TRAVEL
UNIVERSITY TAFE
OTHER
*
Defined
Occupation:
ACADEMIC
ACCOUNTANT
ACTOR
ACTUARY
ADMIN
ADVISOR
AGED CARE
AGENT
AGRICULTUR
AIR HOSTES
AIRPORT
ANALYST
ANIMAL WEL
ARCHITECT
ARMY
ARTIST
AUDIOLOGIS
BAKER
BANK MGR
BANK OFFIC
BARISTA
BARRISTER
BARTENDER
BEAUTICIAN
BOOKKEEPER
BRICKLAYER
BROKER
BUILDER
BUS DRIVER
BUTCHER
CABINETMAK
CAFÉ OWNER
CAREER ADV
CARER
CARETAKER
CARPENTER
CARPET LAY
CATERER
CEO
CFO
CHEF
CHEMIST
CHILDCARE
CHIROPRACT
CLEANER
CLERGY
COMPUTER
CONCRETER
CONSULTANT
COOK
COUNCELLOR
COUNCIL WO
COURIER
CUSTOMER S
DECORATOR
DEFENCE
DELIVERY
DENTIST
DESIGNER
DIETICIAN
DIRECTOR
DOCTOR
DRAFTSPERS
DRESSMAKER
DRIVER
DRYCLEANER
ECONOMIST
EDITOR
ELECTRICAN
ELECTRONIC
ENGINEER
ENTERTAINE
EVENTS MGR
FACTORY SU
FACTORY WO
FARMER
FILM MAKER
FIN CONTRO
FIN PLANNE
FIREMAN
FISHERMAN
FITTER
FLEET MGR
FLIGHT ATT
FLORIST
FOOD TECHN
FOREMAN
GAMING
GARDENER
GLAZIER
GRAPHIC DE
HAIRDRESSE
HANDYMAN
HISTORIAN
HOMEDUTIES
HOMEOPATH
HR ADMIN
HR MANAGER
IMPORTER
INSTRUCTOR
INSURANCE
INTERIORS
INTERPRETO
INVESTOR
IT CONSULT
JEWELLER
JOINERY
JOURNALIST
JUDGE
KITCHEN HA
LAB ASSIST
LABOURER
LANDSCAPER
LAWYER
LECTURER
LIBRARIAN
LOCKSMITH
LOGISTICS
MAINTAINEN
MAKE UP AR
MANAGER
MANICURIST
MANUFACTUR
MARKETING
MASSUER
MATERNITY
MECHANIC
MERCHANDIS
METAL WORK
MINISTER
MODEL
MUSICIAN
NANNY
NATUROPATH
NURSE
NUTRITIONI
OCC.THERAP
OH & S
OPERATIONS
OPTICIAN
OPTOMESTRI
ORDERLY
OSTEOPATH
OTHER
OWNER
PAINTER
PANEL BEAT
PARALEGAL
PARAMEDIC
PARTY PLAN
PASTRYCOOK
PATHOLOGY
PAYROLL
PHARMACIST
PHOTOGRAPH
PHYSIOTHER
PILOT
PLASTERER
PLUMBER
PODIATRIST
POLICE
POSTAL
PRINCIPAL
PRINTER
PRODUCER
PROFESSOR
PROPERTY
PSYCHIATRI
PSYCHOLOGI
PUBLIC REL
PUBLIC SER
PUBLISHER
PURCHASING
QUALITY CO
RACING
RADIOGRAPH
RANGER
REAL ESTAT
RECEPTIONI
RECREATION
RECRUITMEN
REFLEXOLOG
REGISTRAR
REMOVALIST
RESEARCHER
RETIRED
ROOFER
SALES ASSI
SALES MGR
SALES REP
SCIENTIST
SEAMAN
SEAMSTRESS
SECURITY G
SHARE TRAD
SHERIFF
SHOPFITTER
SIGNWRITER
SINGER
SOCIAL WOR
SOFTWARE
SOLICITOR
SPECIALIST
SPORTSMAN
SPRAYPAINT
STOCKBROKE
STOREMAN
STUDENT
SUPERMARKE
SURVEYOR
TAFE
TAILOR
TAXIDRIVER
TEACHER
TECHNICIAN
TELECOMMUN
TELEMARKET
THERAPIST
TILER
TOOLMAKER
TOURISM
TOWN PLANN
TRADESPERS
TRAINER
TRANSLATOR
TRANSPORT
TRUCKDRIVE
TUTOR
UNEMPLOYED
UNION REP
UNIVERSITY
UPHOLSTERE
VALUER
VET
VOLUNTEER
WAITER
WEB DESIGN
WELDER
WELFARE OF
WHARFIE
WHOLESALER
WRITER
YOUTH WORK
ZOO KEEPER
*
Suburb in which you
Work:
What is your partners occupation
(if
applicable)
ACADEMIC
ACCOUNTANT
ACTOR
ACTUARY
ADMIN
ADVISOR
AGED CARE
AGENT
AGRICULTUR
AIR HOSTES
AIRPORT
ANALYST
ANIMAL WEL
ARCHITECT
ARMY
ARTIST
AUDIOLOGIS
BAKER
BANK MGR
BANK OFFIC
BARISTA
BARRISTER
BARTENDER
BEAUTICIAN
BOOKKEEPER
BRICKLAYER
BROKER
BUILDER
BUS DRIVER
BUTCHER
CABINETMAK
CAFÉ OWNER
CAREER ADV
CARER
CARETAKER
CARPENTER
CARPET LAY
CATERER
CEO
CFO
CHEF
CHEMIST
CHILDCARE
CHIROPRACT
CLEANER
CLERGY
COMPUTER
CONCRETER
CONSULTANT
COOK
COUNCELLOR
COUNCIL WO
COURIER
CUSTOMER S
DECORATOR
DEFENCE
DELIVERY
DENTIST
DESIGNER
DIETICIAN
DIRECTOR
DOCTOR
DRAFTSPERS
DRESSMAKER
DRIVER
DRYCLEANER
ECONOMIST
EDITOR
ELECTRICAN
ELECTRONIC
ENGINEER
ENTERTAINE
EVENTS MGR
FACTORY SU
FACTORY WO
FARMER
FILM MAKER
FIN CONTRO
FIN PLANNE
FIREMAN
FISHERMAN
FITTER
FLEET MGR
FLIGHT ATT
FLORIST
FOOD TECHN
FOREMAN
GAMING
GARDENER
GLAZIER
GRAPHIC DE
HAIRDRESSE
HANDYMAN
HISTORIAN
HOMEDUTIES
HOMEOPATH
HR ADMIN
HR MANAGER
IMPORTER
INSTRUCTOR
INSURANCE
INTERIORS
INTERPRETO
INVESTOR
IT CONSULT
JEWELLER
JOINERY
JOURNALIST
JUDGE
KITCHEN HA
LAB ASSIST
LABOURER
LANDSCAPER
LAWYER
LECTURER
LIBRARIAN
LOCKSMITH
LOGISTICS
MAINTAINEN
MAKE UP AR
MANAGER
MANICURIST
MANUFACTUR
MARKETING
MASSUER
MATERNITY
MECHANIC
MERCHANDIS
METAL WORK
MINISTER
MODEL
MUSICIAN
NANNY
NATUROPATH
NURSE
NUTRITIONI
OCC.THERAP
OH & S
OPERATIONS
OPTICIAN
OPTOMESTRI
ORDERLY
OSTEOPATH
OTHER
OWNER
PAINTER
PANEL BEAT
PARALEGAL
PARAMEDIC
PARTY PLAN
PASTRYCOOK
PATHOLOGY
PAYROLL
PHARMACIST
PHOTOGRAPH
PHYSIOTHER
PILOT
PLASTERER
PLUMBER
PODIATRIST
POLICE
POSTAL
PRINCIPAL
PRINTER
PRODUCER
PROFESSOR
PROPERTY
PSYCHIATRI
PSYCHOLOGI
PUBLIC REL
PUBLIC SER
PUBLISHER
PURCHASING
QUALITY CO
RACING
RADIOGRAPH
RANGER
REAL ESTAT
RECEPTIONI
RECREATION
RECRUITMEN
REFLEXOLOG
REGISTRAR
REMOVALIST
RESEARCHER
RETIRED
ROOFER
SALES ASSI
SALES MGR
SALES REP
SCIENTIST
SEAMAN
SEAMSTRESS
SECURITY G
SHARE TRAD
SHERIFF
SHOPFITTER
SIGNWRITER
SINGER
SOCIAL WOR
SOFTWARE
SOLICITOR
SPECIALIST
SPORTSMAN
SPRAYPAINT
STOCKBROKE
STOREMAN
STUDENT
SUPERMARKE
SURVEYOR
TAFE
TAILOR
TAXIDRIVER
TEACHER
TECHNICIAN
TELECOMMUN
TELEMARKET
THERAPIST
TILER
TOOLMAKER
TOURISM
TOWN PLANN
TRADESPERS
TRAINER
TRANSLATOR
TRANSPORT
TRUCKDRIVE
TUTOR
UNEMPLOYED
UNION REP
UNIVERSITY
UPHOLSTERE
VALUER
VET
VOLUNTEER
WAITER
WEB DESIGN
WELDER
WELFARE OF
WHARFIE
WHOLESALER
WRITER
YOUTH WORK
ZOO KEEPER
*
8.
Business
Owners:
Name of Business:
*
Type:
ACCOUNTING
ARTS
ARCHITECT
BANK/FINANCE
CHARITY
CHILDCARE
CONSTRUCTION
CONSULTANT
COUNCIL
CUSTOMS
DESIGN
EDUCATION
ELECTRICIAN
ENGINEER
ENTERTAINMENT
FASHION
FINANCE
GOVERNMENT
HEALTHCARE
HOSPITALITY
INSURANCE
INFO. TECHNOLOGY
LEGAL
MANUFACTURING
MARKETING
MEDIA
MEDICAL PROFESSIONS
POLICE
PROPERTY
PUBLISHING
RECRUITMENT
RETAIL
SCHOOL
SECURITY
SHIPPING
SKILLED TRADE
SOCIAL WORK
TELECOMMUNICATIONS
TOURISM
TRANSPORT
TRAVEL
UNIVERSITY TAFE
OTHER
*
No. of Employees:
1-5
6-10
11-20
21-50
51-100
101-200
201-300
301-500
501-1000
1001+
*
Turnover:
<$500k
$500k-1M
$1M-2M
$2M-10M
$11M-20M
$21M-100M
$100M plus
*
Main Business bank:
ANZ
Arab Bank
Bank of Melbourne
Bendigo
CBA
Citibank
Credit Union
HK
HSBC
ING
MACQUARIE
NAB
OTHER
ST GEORGE
WESTPAC
OTHER
*
9.
Credit cards held
(choose whichever apply) :
AMEX
BANKCARD
DINERS
STORE CHARGE
VISA
MASTERCARD
NO CARD
OTHERS
AMEX
BANKCARD
DINERS
STORE CHARGE
VISA
MASTERCARD
NO CARD
OTHERS
AMEX
BANKCARD
DINERS
STORE CHARGE
VISA
MASTERCARD
NO CARD
OTHERS
AMEX
BANKCARD
DINERS
STORE CHARGE
VISA
MASTERCARD
NO CARD
OTHERS
10.
What bank do you have your main account with :
ANZ
Arab Bank
Bank of Melbourne
Bendigo
CBA
Citibank
Credit Union
HK
HSBC
ING
MACQUARIE
NAB
OTHER
ST GEORGE
WESTPAC
OTHER
What type of account(s) do you have?
Savings Account
Cheque
Investment
11.
These questions relate to your main car(s):
Car Make :
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
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
Car Model :
Year of Manufacturer :
Car insured with :
(10 characters max.)
Is this a company car :
No
Yes
12.
Do you have pets (how many):
Cat Dog
13.
Do you have any
children living at home, if so what is their year of birth :
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):
Interested in attending Groups/Interviews/Clinics ? :
14.
Into which of the categories listed does the income of the entire
household belong?
Under $40,000 per year
40k - $49,999 per year
40k - $49,999 per year
50k - $69,999 per year
70k - $89,999 per year
50k - $69,999 per year
90k - $99,999 per year
100k - $119,999 per year
120,000 or more per year
15.
Do you smoke cigarettes :
No - Do not Smoke
ALPINE
B&H
DUNHILL
HORIZON
LONGBEACH
MARLBORO
MENTHOL
PETER JACKSON
ROLLIES
PETER STYVESANT
WINFIELD
OTHER
NO - Do not Smoke
Do you have Pay TV :
No
AUSTAR
FOXTEL
OPTUS
OTHER
Do you have Private Health
Insurance with :
None - Do not have Insurance
AUSTRALIAN UNITY
BUPA
EMPLOYER
GREATER UNION
HCF
MBF
Medibank
MU
NIB
NO
NRMA
Other
Do you have
any Health Condition:
No
Arthritis
Asthma
Back Pain
Cholesterol
COPD
Crohns
Depression
Diabetes1
Diabetes2
Eczema
Epilepsy
Glaocoma
Hay Fever
Hearing
Heart Disease
High Blood
Incontinence
Insomnia
Low Blood
Migraines
MS
Obese
Osteoporosis
Parkinsons
Stroke
Thyroid
Visually
No
Arthritis
Asthma
Back Pain
Cholesterol
COPD
Crohns
Depression
Diabetes1
Diabetes2
Eczema
Epilepsy
Glaocoma
Hay Fever
Hearing
Heart Disease
High Blood
Incontinence
Insomnia
Low Blood
Migraines
MS
Obese
Osteoporosis
Parkinsons
Stroke
Thyroid
Visually
No
Arthritis
Asthma
Back Pain
COPD
Crohns
Depression
Diabetes1
Diabetes2
Eczema
Epilepsy
Glaocoma
Hay Fever
Hearing
Heart Disease
High Blood
Cholesterol
Incontinence
Insomnia
Low Blood
Migraines
MS
Osteoporosis
Parkinsons
Stroke
Thyroid
Visually
Have you taken part in Market
Research Groups/Interviews/Clinics before:
No
Yes
Comments :
Thank you