Register to Take Part in Market Research!

Please complete this short form to register on our database to take part in upcoming market research projects. If any section of the form is not applicable to you, please leave it blank.

Please note that none of the information provided will be passed on to any third parties.

Firstname(s)
Lastname
House Number
Street or house name
1st line of address
Area/Suburb
Town/City
County
Postcode
Home phone no.
Mobile phone no.
Work phone no.
Email address (note: please avoid Hotmail addresses if possible. If you have to use Hotmail, then please add field@select-research.com to your trusted senders list, after you've completed this form)
I am	male female
I regard my ethnic origin to be	please select an option Bangladeshi Black - African Black - Caribbean Black - *other Chinese Indian Irish Pakistani White *Other prefer not to say
If *others above, please specify
Date of birth	day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 month January February March April May June July August September October November December year:
My marital status is	please select an option Single Cohabiting Married Other
Children?	yes no
Working status	please select an option Student Working Part Time Working Full Time Not Working Unemployed Other
Occupation (if applicable)
How did you find out about us?	Google Other Search Engine Twitter Facebook Friend or Family Advert Other - please give details in box below
Your Select Research promotional code (if you were given one)
Please tick the box to indicate that you have read and understand the information below, and that you agree to take part in the scheme

By completing the form above, I give permission for the information I've provided to be held confidentially and securely by Select Research Ltd in accordance with the Data Protection Act 1998 for the sole purpose of inviting me to participate in market research for Select Research Ltd. I understand that I have the right to have my information deleted from the Select Research database at any time.

Select Research is registered in the West Midlands and the registered number of the company is 2921698. Registered office is 42, Calthorpe Road, Edgbaston, Birmingham, B15 1TS.