Florida Focus Group

Event Date

Name:

First

Middle

Last

Phone:

Area Code

-

Phone Number

E-mail:

Race:

Gender

Male

Female

Date of Birth:

Place of Birth

Marital Status

Married

Single

Divorced

Current Employer

Job Description

How long Employed there?

if self-employed, name of company & type of business

Location (City & State)

Highest grade in School

Total family income

$0-$41K

$41k-$75k

$75k-$100k

$100k+

Have you ever served in the U.S. Military?

Yes

No

Have you ever been convicted of a Felony?

Yes

No

Ever been a party to a lawsuit (other than a divorce)?

Yes

No

If YES, Please provide details

Have you ever served on a Jury?

Yes

No

If YES, Please provide details

Have you ever participated in a Focus Group before?

Yes

No

If YES, what kind of Focus Group?

Name of the last book you read?

What magazines do you like to read?

How many times a week do you watch the news?

What is your favorite movie genre?

Which newspaper(s) do you read?

What are your hobbies?

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