West Coast Field Services
1st Floor
47 Kishorn Road
Applecross WA 6153
Australia

Ph. +618 9316 3366
Fax. +618 9316 9117

Get Paid For your Opinions!

We often need to organise small groups of people to take part in informal discussions about various topics, from ice cream to alcohol and social issues- in fact it could be anything.

If you are interested in joining 8 -10 people for an interesting and informal discussion, we invite you to register to take part. We offer refreshments and the groups usually last for an hour and a half. Those who take part are paid for their participation.

There is never any obligation, your name will not be used for any other purpose.

If you would like to be part of it, please fill in the form below. Alternatively, you could give us a call at (08) 9316 3366 or email to onlinesurveys@wcfs.com.au

 

Focus Group - New Member Registration Form

Already a member ? - Call us on 9316 3366 or email recruit@wcfs.com.au to update your details

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.  

  Contact Details  
  First Name :
  Surname :     Title:
  Address :   (optional)
Suburb:
Postcode : State :  
  Telephone - Home :  
Telephone - Work :  
Telephone - Mobile :      
      
  Email Address :
 


Please, re-type the Email here:
* 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 checking please re-type)
Email Check Frequency :  

...
  About You   
  Gender :  
Marital Status :
Country of Birth:
(original nationality)
If born outside of Australia, what year did you arrive
Date of Birth : Day (01-31) / Month (01-12) / Year (1900-)
Often we need to send invitations to specific age groups. Filling in your date of birth allows us to calculate your age over time. If you do not wish to include your precise date of birth, please specify al least the month and the year of your birth. Remember you are protected by Federal Privacy Laws.
  Employment
 
  Job Title :

  (30 characters max.)
Employment Type:
Which of the following categories best describes your occupation ?
Do you own your own business ?      No. of Employees:
What level of education have you reached, so far ?
Which of the following categories best describes your partner's occupation ? (if applicable)   
Other Details:

...
  Do you have any children ?

if so, please specify the year(s) in which they were born (in YYYY format,  ex. 1998) :		    Yes     No   


    Child BOY, year of birth :  
    Child BOY, year of birth :  
    Child BOY, year of birth :  
    Child BOY, year of birth :  
    Child GIRL, year of birth :
    Child GIRL, year of birth :
    Child GIRL, year of birth :
     Child GIRL, year of birth :
  Household Income  ?
  Your Preferences
 
  Do you drink any of the following ?
(Please tick whichever apply) :
  Beer         Wine      Spirits     Other (alcoholic)
  Do not drink alcohol
  Tea          Coffee     Flavoured Milk  
  Do you smoke ?
 Yes     No   
  Which bank do you have your main account with ?
  Do you have Private Health Insurance ?
  Do you have Car Insurance ?
  Do you have Home & Contents Insurance ?

  And finally...
 
How did you hear about us ?


Thank you.