Registration Form

Please fill in the questionnaire below. We ask for this information to enable us to match your criteria to the projects we receive.
This means that by the time we ring you 90% of the criteria fits the Clients requirements, and all we need to know now is whether you can make the time and place. Feedback Research strictly adheres to The Data Protection Act and at no time will any of your data be given to anyone who does not work for our Company.

Alternatively - and if you use Outlook as an email client, you can fill in the questionnaire by downloading it as a PDF > Click here to download

Personal Information (fields marked with * are required).

Full Name*: Gender:

Date of Birth, DD/MM/YYYY: Ethnic Origin:

Address: Post Code*:

E-Mail*: Tel: (Home):

Tel: (Mobile): Tel: (Work):

Marital Status: How Many Children Do You Have?

Please State Ages, School Year, Sex and Name of Schools for each Child:

Employment Information Main Wage Earner

Occupation: Job Title:

Company Name:

Company Location: No. of Employees on site:

No. of employees in UK:

No. of Employees Worldwide:

Managerial Position (Please answer YES or NO):

If YES, how many people are you/they responsible for?

How many Direct Reports?

Qualifications & Degrees attained, please state below if required for work:

Employment Information Secondary Wage Earner

Occupation: Job Title:

Company Location: No. of Employees on site:

No. of employees in UK:

No. of Employees Worldwide:

Managerial Position (Please answer YES or NO):

If YES, how many people are you/they responsible for?

How many Direct Reports?

Qualifications & Degrees attained, please state below if required for work:

Car Information

Do you own a car less than 5 years old? If YES, please complete this section

Car Manufacturer: Car Model:

New or Secondhand: Car Year:

Who owns the car? Company, Private, Leased, Hired:

Breakdown Service:

Which Insurance Company Do You Use?

Miscellaneous

Do you subscribe to any of the following Sky, Sky +, Cable, Freeview, Online Television Services? Please state which.

Do you belong to a private medical insurance company?If so what company?

Company Scheme? Yes/No: Mobile Phone Operator:

Please list which banks or building societies you use:

What is your main store used for your food shopping?

What is your dress size?

Please list which newspapers and magazines you read:

Do you suffer from hayfever, eczema, asthma, diabetes: If so, Which:

Do You Smoke? If you do smoke, which brand?

How many do you smoke per day?

Do you wear glasses or contacts? Please state which:

Which brand of contact lens do you wear and what frequency used eg daily / monthly:

What is the name of your Internet Service Provider?

Are you a Vegetarian?

Does anyone in your household have a disability - if so please state who and what: