Sample Research Inc.

SAMPLE COMPANY
xxx West Loop South, Ste. xxx
Houston, Tx. xxx

Sample Survey

We are continually seeking new people of all ages to participate in many different studies. This is your chance to voice your opinions and ideas about different products, advertising or services offered by manufactures, medical institutes, even local and national government agencies. We do not sell anything. Our studies are conducted for evaluation only. We compensate you for your time in the form of cash, gift, or donations to your favorite charity.

Please provide us with the following information:

Full Name		E-mail
Business Phone	Fax	Home
Address
City	State	Zip
Year Born	Gender	Ethnicity
Occupation	Title	Industry

Marital Status		Approx. Annual House Hold Income
Number of Children		Year of Each Birth (ie. 67,72,88)
Do You Own Your Home?		Highest Level of Education

Do You Smoke?		Do you drink alcoholic beverages?
Beer?		Wine?
Mixed Drinks?		Other?
Are you registered to vote?		Political Affiliation
Do you have a pager?		Do you have a cellular phone?

What is the make, model & year of your vehicles:

MAKE	MODEL	YEAR

Own a motorcycle?

Own a watercraft?

How many hours do you spend on your computer per week?

How many hours do you spend on the internet per week?

What pointing device do you use?

What operating system do you use for your computer?

What kind of processor does your computer have?

Which of the following do you currently own?

Who is your current ISP?

Please rate your familiarity with each of the following:
(Where 0 = Never Done / 5 = Competent / 10 = I Could Do In My Sleep)

	Create a document with a program like Microsoft Word/Word Perfect.
	Create a spreadsheet with a program like Microsoft Excel/Lotus 1-2-3.
	Keep track of household finances with a program like Quicken.
	Play games.
	Send e-mails.
	Download software from the internet.
	Use performance enhancing software such as Microsoft Scan Disk to increase the performance of your personal desktop.
	Send faxes using your desktop computer.
	Install an internal modem or other card into the computer.