Participate

Are you interested in participating in a focus group as a respondent?

At Columbia Focus we are committed to attracting the highest quality respondents to participate in our focus groups. This respondent form is designed for those who are interested in participating in a focus group and are not currently registered in our database. The information you provide will remain confidential. Please fill the form out completely to help us accurately determine where you would best qualify to participate in our focus group panel discussions.

First Name:
Last Name:
Date of Birth (mm/d/yy):
Race:
Gender:
Street Address:
City:
County:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone (if applicable):
Email Address (if applicable):
Highest Level of Education:
Occupation:
Household Income:
Marital Status:
Number of Children under 18 living at home:
Political Party Affiliation:
Registered Voter?	Yes No
Ever been in a Focus Group?	Yes No How long ago?
Topic of last Focus Group?

If you are concerned about sending personal information across the Internet, you can print this form and mail or fax it directly to us at the following address:

Columbia Focus LLC
3300 North Ridge Road, Suite #280
Howard County Executive Center
Ellicott City, MD 21043
fax: (410) 480-3232