Registration Form

Basic Personal / Contact Information
Title
First Name
Last Name
Email Address
Confirm Email Address
Home Address
Town
County
Postcode
Mobile Number
Home Tel Number
DOB
Day Month Year
Age
Gender
Male   Female
Living in the UK since
Martial Status
Level of Education
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Other
Residence
Type
Ethnicity
Ethnicity
Occupation - Self
My Working Status
Occupation
Industry worked in
Is Your Occupation Full-time or Part-time
Occupation - Partner
Partners Working Status
Occupation
Industry worked in
Is Your Partners Occupation Full-time or Part-time
Children
How Many Children Live At Home With You?
Children's Details
Child 1
DOB
Day Month Year
Age Gender
Male   Female
Child 2
DOB
Day Month Year
Age Gender
Male   Female
Child 3
DOB
Day Month Year
Age Gender
Male   Female
Child 4
DOB
Day Month Year
Age Gender
Male   Female
Newspaper
Which Newspaper(s) do you read regularly?
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Car
My Car - Owned or Company Car
My Car - Type
My Car - Manufacturer
My Car - Model
My Car - Year of First Registration
Car 2 - My Partners Car
My Partners Car - Type
My Partners Car - Manufacturer
My Partners Car - Model
My Partners Car - Year of Registration
Car 3 - Other Car In Household
Other Car In Household - Type
Other Car In Household - Manufacturer
Other Car In Household - Model
Other Car In Household - Year of Registration
Bank and Savings / Investment Account
With Which of The Following Do You Have An Account?
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Pension & Health Insurance
Are You A Member of A Company Pension Scheme?
Are You A Member of A Private Pension Scheme?
Do You Have An ISA?
Do You Have Private Health Insurance?
What Is The Name Of Your Private Health Insurance Provider
Credit Cards
Which of The Following Credit Cards Do You Have?
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If Other Please State
Cigarettes
Do You Smoke Cigarettes
If Yes, Which Brand of Cigarette Do You Smoke Most Often?
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If Other Please State
Alcohol
Which of The Following Do You Drink?
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Food Shopping
Where Do You Mainly Shop For Food?
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Medical
Do You Wear Contact Lenses?
Do You Wear Spectacles?
Do You Have Either of The Following Medical Conditions?
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Computer/Mobile Phone/Broadband/TV
Computer Used At Work?
Computer Used At Home?
Do You Purchase Goods On Line?
Do You Use Online Banking?
Do You Have A Personal Mobile Phone?
What Network Is This Phone On?
What Tariff Are You On?
Which of The Following Do You Own/Use?
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Which of The Following Satallite, Digital or Cable TV Do You Subscribe To At Home?
Do You Use Only Terrestrial TV In Your Home?
Is Freeview TV In Use At Your Home?
Broadband Used At Home?
Name of Broadband Provider
If Other Please State
Landline Telephone Used At Home?
Name of Provider
If Other Please State
Privacy
I agree that the data I supply to Focus For Research can be held in accordance with their Privacy Policy
Yes   No
To complete your registration and to be offered the opportunity to participate in paid market research, I agree you can contact me by:
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