Thank you for your interest in our focus group.  If you are selected to participate, you will be contacted by email and/or phone no later than February 14.  All questions are required to be completed.  If you have any questions, contact Hardy & Hardy Media Marketing at (304) 281-7059.

    Name
    Phone
    Email

    Date of Birth

    Address (Street, City, State)

    Occupation
    Employer

    Education

    Marital Status?

    Spouse’s Name
    Spouse’s Occupation

    Do you have any children?

    If so, names and ages

    Do you own property/pay real estate taxes in Belmont County:

    Have you ever served on jury duty before?

    If so, what court/when ?

    Do you or any family members work in the insurance industry?

    Would you be willing and able to keep the subject matter and information discussed at the upcoming meeting confidential?

    Would you consent to the audio/video recording of the upcoming meeting?

    PARTICIPANT RELEASE FORM


    By signing this form, I agree to take part in a focus group/promotional campaign conducted by Hardy & Hardy Media Marketing.

    I allow my input, likeness, voice and photo to be used in all areas of the campaign, which may include: television, radio, ¬newspaper, billboard and web.

    If chosen, I understand that I will be compensated with lunch and $50 for my involvement.

    Our Office.

    Kinglake West VIC 3757. Melbourne, Australia
    Call: +61383766284