Share Your Insights

Create a Profile

Please fill out the form below to create your profile. Please provide as much information as possible.

Respondents who provide more information are more likely to be selected for a study and get paid!

Contact Information

First Name	Middle Initial	Last Name
Address
City	State	ZIP Code
County	Home Phone	Work Phone
Cell Phone	Fax Number	E-mail Address
Cell Phone Provider

Demographic Information

Ethnicity		Gender
Primary Language		Other Languages Spoken
Marital Status		Rent or Own your residence?
Household Income		Education
We recruit users from many age groups. Please choose your Birth Month and Year		Health Conditions if Any?
Do you have children under 18 at home?	Yes No	Sexual Orientation

Experience Information

Employment Status		What is Your Work Title?
Are you a small business owner?		Select Your Industry Type
Functional Area		Who is your Employer?
Number of Employees at Your Company		How many times have you traveled in the past 12 months?
Do you travel mostly for		Are you a member of Rewards/Loyalty Programs?

Your Technology Use

Referral Information

Did someone refer you to Shareyourinsights.com?

If you think any of your friends or family would also be interested in participating in a research study, please provide their email addresses in the fields below and we will send them an email invitation to sign up.

Name
Phone
Email
Relationship

Name
Phone
Email
Relationship

Name
Phone
Email
Relationship

We appreciate your time and look forward to working with you in the future.

My signature below affirms that I have agreed to participate in a one-on-one session administered by User Insight, and that all answers I have given to screening questions are the truth to the best of my knowledge. I understand that the research project I am participating in today is confidential, and agree that what I observe will be held in strictest confidence. I am aware that the one on one session will be audio and video taped, and/or observed for marketing research purposes only, not for commercial use. I am also aware that the session will last 1 ½ to 2 hours.

I Agree with the disclaimer

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