Mid-America Research Respondent Information Form

Thank you for your interest in the Mid-America Research Respondent Information Form. Since 1967 MAR has been dedicated to the privacy and security of all our research participants. The information you input today will be added to our panel of thousands of respondents collected over the past three decades. Based upon your responses, research studies will be selected that are a good fit for your possible participation.

Please note: MAR does not sell information regarding respondents to third parties.

Please tell us about yourself! Name: First Last Address: City: State: select one AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip: Home Phone: Work Phone: Cell Phone: Email Address: Occupation: Household Income: select one less than $15,000 $15,000-$24,999 $25,000-$34,999 $35,000-$49,999 $50,000-$74,999 $75,000-$99,999 greater than $100,000 Education: select one less than High School High School Some College College Graduate Post Graduate Date of Birth: month select Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec day select12345678910111213141516171819202122232425262728293031 year (YYYY) Gender: Male  Female   Ethnic Background: select one African American Asian Caucasian Hispanic Other Type of Residence: select one House Condo Apartment Townhouse Other       Owned  Rented   Marital Status: select one Married Single Separated/Divorced/Widowed Living Together Please tell us about your spouse, if you have one! Spouse's name: First Last Spouse's Date of Birth: month select Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec day select12345678910111213141516171819202122232425262728293031 year (YYYY) Spouse's Occupation: Spouse's Education: select one less than High School High School Some College College Graduate Post Graduate Do you have any children? Fill in all that apply! Birth Date Gender Child 1 month select Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec day select12345678910111213141516171819202122232425262728293031 year (YYYY) Male   Female Child 2 month select Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec day select12345678910111213141516171819202122232425262728293031 year (YYYY) Male   Female Child 3 month select Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec day select12345678910111213141516171819202122232425262728293031 year (YYYY) Male   Female Child 4 month select Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec day select12345678910111213141516171819202122232425262728293031 year (YYYY) Male   Female Child 5 month select Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec day select12345678910111213141516171819202122232425262728293031 year (YYYY) Male   Female Do you drink alcoholic beverages?     If yes, check all that apply: Beer Wine Champagne Brandy Cognac Cordials Gin Liquers Rum Schnapps Scotch Sherry Tequila Vodka Whiskey Other Alcoholic Beverages Smoking information Do you smoke cigarettes? Yes  No   If yes, brand most often smoked: Does your spouse smoke? Yes  No   If yes, brand most often smoked: Pets Do you own a dog? Yes  No   Do you own a cat? Yes  No   Please tell us about your vehicles. Make Model year Automobile 1 Automobile 2 Automobile 3 Automobile 4 Automobile 5 Airline trips Number of airline trips you have taken in the past 12 months for business: for pleasure:         Number of airline trips your spouse has taken in the past 12 months for business: for pleasure: reset this form