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Antilles
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(GMT -12:00) Eniwetok, Kwajalein
(GMT -11:00) Midway Island, Samoa
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(GMT -8:00) Pacific Time (US & Canada)
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(GMT -3:30) Newfoundland
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(GMT +2:00) Kaliningrad, South Africa
(GMT +3:00) Baghdad, Riyadh, Moscow, St. Petersburg
(GMT +3:30) Tehran
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(GMT +4:30) Kabul
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(GMT +7:00) Bangkok, Hanoi, Jakarta
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(GMT +9:30) Adelaide, Darwin
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Additional information
Do you want to be registered for our mom survey and sampling panel? *
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You'll receive opportunities to try out new products and services and asked your opinion about them.
Your Birth Year
Do you:
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Work Full-time
Work Part-time
Am at home with the kids
Other
None of the above
If you work full or part-time, do you work:
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At home
Out of an office
Both
Do you own your own business?
- Please Choose -
Yes
No
If so, how many employees?
Your Marital Status is:
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Married
In a partnered relationship
Single
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Separated
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What is the highest level of education you have completed or the highest degree you have received?
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Currently a Student
Did not complete high school
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Master/Doctoral/Other Advanced degree
Professional Degree (MBA, JD, MD)
Do you consider yourself:
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White/Caucasian
Black/African American
Asian/Pacific Islander
Hispanic or Latino
Native American/Alaskan Native
Other
Your approximate Household Income
- Please Choose -
<$25K
$26K -50K
$51K – 75K
$76K- 100K
$101K – 150K
$151K+
Are you:
A Homeschooler
Passionate about going green
A Pet Owner
Mom of Multiples
A Teacher
Empty Nester
Caretaker of your parents
Mom of Special Needs Kid(s)
Small Business Owner
Allergy Sensitive kids or family
Passionate about Organic
Homeowner
Are you a leader of any of the following? (Check all that apply)
Troop Leader
Organized sports Team(s)
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PTO/PTA
Organized Playgroup(s)
Cultural & Arts Program(s)
Teacher/Education
Political Group(s)
Religious Group(s)
Homeroom Mom
Other Groups you may be a Leader of
Computer Type
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PC
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Sites You are Active On
MySpace
Facebook
Ning
Gather
Twitter
LinkedIn
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Other Sites
Stores you Shop at
Target
Safeway
Sam's Club
Wal-Mart
Stop & Shop
BJ's
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Omni Foods
Whole Foods
Cosco
Are you a Mom who Blogs?
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If yes, please share your URL
Child Information
Number of Children
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1
2
3
4
5
6+
I'm expecting!
No kids just yet.
Child #1 Birth Date Year
Child #2 Birth Date Year
Child #3 Birth Date Year
Child #4 Birth Date Year
Child #5 Birth Date Year
Child #6 Birth Date Year
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Polls
How interested are you in seeing more recycled, recyclable and "Green" products on the market?
Very interested! I'd love to go completely Green.
Somewhat interested, I'd be willing to pay a little more for Green products.
I would, but they're too expensive!
Not interested at all!
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