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If you are interested in participating in one of our future focus groups, please fill out the information below. This information is for research and screening purposes only and will be kept confidential. It will not be shared, and you will not receive marketing offers as a result of completing this questionnaire.

If you have any problems with this form, please contact susan@opinionworks.com.

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1. Please provide your contact information so we know how to get in touch with you. *This question is required.

Name
Email (please confirm carefully):
City, State
Zip code
Best telephone number to reach you

2. 1. What is your age? *This question is required.

3. 2. What is your gender? *This question is required.