Get Paid for Your Opinion As a registered Taylor McKenzie panel member you can: - Take part in surveys & focus groups on a wide range of topics. - Be the first to see the products and adverts of tomorrow. - Receive cash incentives for taking part, which is always nice!

As a panel member you can be assured that your details will NEVER be passed on to a 3rd party without your express permission. We are full company members of the market research society and as such are governed by strict confidentiality laws. We are a family business and greatly appreciate the trust placed in us by our panel members.

	First Name:
	Surname:
	Date of birth: (dd/mm/yyyy)
	Address:
	Town / City:
	Post Code:
	Tel - Home:
	Tel - Mob:
	Tel - Work:
	Email:

1.	Your Gender
	Male
	Female

2.	Which of the following best describes your occupation?
	Employed Full-Time
	Self Employed
	Employed Part - Time
	Full time student
	Unemployed and looking for work
	Unemployed long term sick
	Unemployed short term sick
	Home maker / Looking after kids
	Retired

3.	What is your job title - Please try to include industry and company size if possible (we do lots of employment / medical research where this info is useful)

4.	What are you studying? (uni & course please)

5.	What was your occupation?

6.	Which of the following best describes your current status?
	Married / Co-habiting
	In a Relationship
	Single

7.	Do you have any children?
	Yes
	No

8.	How many children do you have? (we do lots of research for parents and children, so its always good to know who has kids and what age they are)
	1
	2
	3
	4
	5
	6

	Child 1 - D.ORR.B (dd/mm/yyyy)
	Child 1 - Gender
	Child 2 - D.ORR.B (dd/mm/yyyy)
	Child 2 - Gender
	Child 3 - D.ORR.B (dd/mm/yyyy)
	Child 3 - Gender
	Child 4 - D.O.B (dd/mm/yyyy)
	Child 4 - Gender
	Child 5 - D.O.B (dd/mm/yyyy)
	Child 5 - Gender
	Child 6 - D.O.B (dd/mm/yyyy)
	Child 6 - Gender

We know this is taking a while, so all information from here on is completely optional (if you dont have time just go down to submit). However the more information you provide then the easier it is to get you along to specific research projects.

9.	Do you Smoke?
	Yes
	No

10.	Mobile Network
	O2		Vodaphone
	Orange		Tesco Mobile
	Virgin		Other
	3		No Mobile
	T-Mobile

Please specify 'other'

11.	Mobile Contract
	PAYG
	Contract

12.	Broadband Provider
	BT		O2
	Talk Talk		Plusnet
	Sky		AOL
	Virgin		Other
	Orange		No Broadband in House

Please specify 'other'

13.	Which of the following best describes your current TV set-up:
	Analogue only		Virgin Media
	Digital Freeview only		BT Vision
	SKY TV Package		No TV in household

14.	Please tell us which of the following best describes your grocery shopping habits in each of the following Supermarkets.
		Main Shop		Top-up Shop		Rarely use		Never use
	Sainsbury's
	Tesco
	Morrisons
	ASDA
	Waitrose
	M&S
	Lidl
	ALDI
	Iceland
	Co-op

15.	Who do you bank with (please tick all that apply)?
	RBS		Halifax
	BOS		Santander
	Lloyds TSB		Tesco
	Nat West		Sainsburys
	Barclays		Egg
	HSBC		Other
	Co-operative Bank

Please specify 'other'

16.	What make and model of car do you drive ? please specify car year (if not applicable please write N/A)

17.	Who is your electrical supplier? (if not applicable please write N/A)

18.	Who is your gas supplier? (if not applicable please write N/A)

19.	Do you suffer from any of the following: (This section is completely optional, please be assured all information provided will remain confidential)
	Physical Disability
	Medical condition (asthma, psoriasis, diabetes etc)
	Mental Illness

	Please describe your physical disability
	Please describe your medical condition/s
	Please describe your mental illness

20.	Which of the following best describes your ethnic background?
	White		Pakistani
	Black Caribbean		Bangladeshi
	Black African		Chinese
	Indian		Other (please write in)

Please specify 'other'