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Personal data

Address *  
First Name * Last Name *
Telephone * Cellphone
Street Street Number
ZIP Code City *
State * Place of employment *
E-mail address * Date of birth (month/year) *
Marital status Children
Youngest child's year of birth Oldest child's year of birth
School education *  
Occupation Business
In which sector are you working? Company size

Motor car possession

Motor car possession Yes No  
Initial registration of motor car Motor car brand
Motor car model Motor car body
Type of vehicle (at point in time of purchase Drive technology

Which of the following devices are used in your household?

PC Yes No Source of supply of your PC
PC operating system  
Notebook Yes No iPad/Tablet PC
Notebook operating system  
Digital camera Yes No DVD recorder Yes No
Blu-ray player Yes No  
TV Game console
Cellphone Manufacturer Cellular phone system provider
Cellphone contract Mobile internet connection
Landline provider Internet provider
Landline connection Internet connection
Voice over IP Yes No Voice over IP provider

Which of the following products do you consume on a regular basis or which brands do you prefer?

Beer Wine
Regular brand of shower gel Regular brand of antiperspirant

Other

Smoker Yes No Cigarette brand
Pets Pet food
Accomodation Electricity supplier
Diabetic Yes No Dominating hand
Experience in on-line communities Yes No Do you have a homepage? Yes No
Last air trip How many flights per year (approx.)
Were the flights… What class?
Experience in market research Yes No How did you find out about our services?
Message
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