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Register with Us

Please take a moment to fill out the following form. We appreciate your interest in Lakamo Recruiting and look forward to matching you with an appropriate focus group soon!

Please fill out an individual form for each member of your family who might like to participate. If you would like to input information for more than one person, you will be given the opportunity to do so after submitting the form.

Note: Required fields are marked with an asterisk (*) however you can enter "None" in any required field where you do not have information to share.

:: Your personal Information:
Name:
* First Name
* Last Name
Home E-Mail Address:
Phone Info:
Day Phone      Extension
    
* Evening Phone      Extension
    
Mobile Phone      Extension
    
City & State:
City
State
Occupation :
Education:
Date of birth:
Gender:
Family Info:
Marital Status
Total Children
Ethnicity:
Glasses:
Prefered Hand:
Car Year
(yyyy):

:: Your online information:
ISP Info:
ISP
ISP Type
Internet Browsing:
Browser
Internet Explorer
Netscape
AOL
CompuServe
Other
     Search Engine
Google
Lycos
MSN
Netscape
Yahoo
Other
Home Page:
Online services/activities you participate in:
Browse Business
Celebrities Chat Rooms
Finance Games
Health Horoscope
Instant Messaging Men's Topics
Movies Music
News Parenting
Personals Photo of the Day
Polls Shopping
Sports Travel
Weather Women's Topics

:: Miscellaneous information:
When are you typically available to participate in a study?
Day
Evening
Who were you referred by? (if applicable)
Abby Gregory
Amy Francis
Christina Brams
Connie Hedden
Elaine Hansen
Jeaneen Eckhardt
Kari Santry
Laurie Mohler
Matt Wallace
Meagan Scheetz
Nicole Angulo
Nina Menduni
Renee Stephens
Sandy Thompson
Terri Fisher
Other *
* If other, please specify:

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