Millward Brown (Australia) v4.1

GENEROUS RE-IMBURSEMENT FOR YOUR OPINIONS

SYDNEY or MELBOURNE

   . Consumer research is a way for companies to obtain valuable feedback about existing and future goods and services. The way in which we conduct our research is by face to face interviews and/or group discussions held in a location near to you. We offer on average, between $40 - $80 (depending on the length of the session, which can vary from 1 - 2 hours) to cover your expenses in attending. Groups may involve observation techniques, such as viewing or recording. Please be assured that we just conduct research and do not promote or sell any products or services.

   . Millward Brown Australia is a member of the AMSRS (Australian Market and Social Research Society), & follows the standards, ethics, and guidelines defined by the AMSRS. We also adhere to the National Privacy Principles, as laid out in the new Privacy Amendment (Private Sector) Act 2000. Your information is treated with the utmost confidentiality and is held in a physically secure and limited access database.

   . If you would like to be added to our database, to attend interviews and group discussions, please complete the questionnaire below. This questionnaire can be filled out by any person over 18 years of age.

Note: Please answer as many questions as possible , the more information you can give us, the easier it is for us to match you to specific research projects. Fields defined in black text are mandatory

. . .

	The State where you live.
1.	Surname :
2.	First Name :	Title:
	Add/Update Information ?
3.	Address :
	Suburb :
	Postcode :
	Suburb in which you work :	(max. 10 characters)
		...
4.	Telephone - Home :
	Telephone - Work :
	Telephone - Mobile :	Provider:
	- Mobile Payment :
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 :
	Group Area Preferred:
		...
6.	Main Income Earner Occupation:
	Main Income Earner Grouping:
	Main Income Earner is :
	Your Occupation is:
	Employed Status :
	Self Employed :	No. of Employees:
	What is your partners occupation (if applicable)
		...
7.	Your Gender :
	Date of Birth :	Day (01-31) / Month (01-12) / Year (1900-)
	Place of Birth :	Year 1st came to Aust. (1900-):

8.	Which Bank do you have your main account with :
		...
9.	These questions relate to your primary car:
	MAKE (ie. Holden) :
	MODEL (ie. Commodore) :

	Year of Manufacturer :
	Car insured with :
	Is this a company car :
		...
10.	Do you have pets:	Cat Dog
	Do you drink:	Beer: Wine: Spirits:
		Spirits: Spirits:
		...

11.	Do you have any children living at home, if so what are their years of birth :	Child BOY, year of birth (YYYY) : 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): Child GIRL, year of birth (YYYY): Are they interested in attending Groups ? :
		...
12.	What is your current marital status :
	What is your current home status :
	In which category does the income of the entire household belong ?
	What is your own income ?
	Are you the main grocery buyer :
		...
13.	Do you smoke cigarettes :	How Often:
	What do you smoke:	Melbourne Resident : Sydney Resident:
	Do you use the Internet :
	Do you have a swimming pool :
	Who is your Pay TV provider :
	Do you have Air-conditioning:
	Regarding Business Travel, is it mainly for :
	Regarding Personal Travel, is it mainly for :
	Do you have Private Health Insurance :
	Main Credit Cards held :
	Superannuation held:
	Politics:
	Feminine Hygiene Type:
	- Brand:
	Multi-vitamins:
	-Brand used:

14.	Where did you hear about us:
	Car Fuel Used:
	Gambling Type:

		Thank you