| First Name* | |
| Last Name* | |
| Email* | |
| Mobile Phone* | |
| What city/town do you live in?* | |
| Zip Code* | |
| In what year were you born?* | |
| Gender* |
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| Ethnicity* |
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| Marital Status* |
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| How many children do you have?* |
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| What is your highest level of education received?* |
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| What is your annual household income?* |
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| Job Title* | |
| Select the interests you would like to be contacted about for future research studies. |
| B2B Tech / Cloud / Engineering | |
| Cars / Autonomous Driving | |
| Design / Art / Decor | |
| Elderly Care / Aging / Assisted Living | |
| Gadgets / Electronics | |
| Health / Healthcare / Medical / Devices | |
| Kids / Education / Family Life | |
| Shopping / Groceries | |
| Smart Home / Home Tech | |
| Travel / Leisure / Entertainment / Gaming | |
| Select Yes for notification on upcoming studies* |
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| Lead Source |
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