Database for Consumer Research Participants


If you live in Greater Los Angeles and are willing to travel to our facility in West Los Angeles to participate in a research project, please complete the following form. The information you submit will be kept completely confidential in our database.

If you prefer to complete a printed registration form, please click HERE to view a PDF form which you may print out, complete and mail to Juárez Associates, Inc.


* Required information.

* Full name:
(first middle last)
* E-mail:
Address:
City:
Primary Tel. #:
Secondary Tel. #:
Job/Occupation:
Racial/Ethnic
Background:
Languages,
other than English:
Your date of birth:
Gender: Female  Male
Marital status: Married  Single  Divorced  Widowed
Children living at home: Yes  No
If Yes,
year(s) of birth:		 #1:   #2:
#3:   #4:
Household income
last year (optional):
... Press SUBMIT to send information.
... Press RESET to clear information.

Thank you for registering for our database. If we are recruiting for a focus group or other research study, we may call you to see if you qualify to participate. If you qualify and are selected, you will be paid in cash for your opinions.