The Talking Shop - The Real List

Be a respondent

Fill in your application online

Fill in the following form to apply to be a market research respondent in Manchester.

About you:

Name

Address

Postcode

Work telephone

Home telephone

Mobile

Email address

Are you male or female?

Male Female

Your date of birth

I am available to take part in research:

Your employment situation

Which one of these best describes your main employment situation at the moment?

Thinking about your main occupation, are you self-employed?

Yes No

What is your job-title?

Qualifications and background

Select the highest qualification you hold:

What is your marital status?

If you are living with a spouse/partner, what is their occupation?

How long have you lived in the UK?

All my life

Since...

Do you hold a UK passport?

Yes No

Ethnicity and children

What do you regard your ethnic origin to be?

Details, if necessary:

If you have any children under 18 living at home with you, please enter their dates of birth:

Child 1 or Oldest Child

Child 2

Child 3

Child 4

Child 5 or Youngest Child

Would you be happy for them to attend groups if, for example, we were researching products aimed at children?

Yes No

Medical conditions

We are sometimes asked to find people who suffer from various medical conditions and who are willing to take part in market research. This does NOT involve testing drugs but is simply about your experiences and opinions. If you or a close family member suffer from any of the conditions below and would be willing to take part in research, please tick where appropriate:

Condition	I have this condition	Close family member has this condition
Diabetes
High Blood Pressure
High Cholesterol
Obesity (BMI over 30)
Heart disease
Stroke
Psoriasis
Cancer
Kidney disease
Liver disease
Hepatitis B
Hepatitis C
Aids
HIV
Parkinson’s disease
Alzheimer’s disease

Terms and Conditions

I confirm that the information I have given is true. I give permission for this information to be held by the Talking Shop/Real List in accordance with the Data Protection Act of 1998. I understand that this information is held for the sole purpose of inviting me to participate in market research.