Platinum Research Panel

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Note : Please DO NOT hit the 'Enter' key while taking this survey. Please scroll down to the bottom of the page and click continue after completing ALL the questions.

* Indicates A Required Field

First Name:

Last Name:

Address:

City:

State:

Zip:

Daytime Phone:

Evening Phone:

Date of Birth:

Email Address:

How did you hear about the Platinum Panel?

	Email Invitation
	Internet Advertisement
	State Fair
	Read Advertisement in Courier-Journal (Main News)
	Read Advertisement in Velocity
	Platinum Business Card
	Radio Advertisement
	Referred by friend or family member Referral #
	Just Cruising The Web
	I'm already a panelist - I'm just updating my information
	Through an organization or club Organization #
	Other

Are you or any member of your household currently employed by a...

a. Marketing Research Company
Yes No

b. A Newspaper Television Or Radio Station
Yes No

c. An Advertising Agency Or The Advertising Department of a Company
Yes No

Do You eat food from fast food restaurants?

Yes No

In an average month,how many times do you order pizza either for carryout or delivery?

Do you drink alcoholic beverages?

Yes No

In an average year, about how many live performing arts events have you attended? (i.e. plays, musicals, operas, etc...)

What type of connection to the internet do you have?

		Dial-up
		Cable/DSL
		Don't Know

Is your email HTML compatible?

		Yes
		No
		Don't Know