Please fill out the form below as completely as possible. Forms with inadequate information may be rejected. After we receive your application you will then be added to the Consumer Connections’ panel for product testing.

Panel Request Form - Personal Information   Organization    Last Name    First Name, MI    Address    City    State    Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other / International Postal Code    Phone    Date of Birth    Email    Ethnic Background    Ethnicity African American Asian American Caucasion Latin American Contact Preference    Contact Email Phone Best time to schedule a call    Best Time Morning 9:00am - Noon Afternoon Noon - 5:00pm Evening 5:00pm - 8:00pm Best time for participating  in product testings    Best Time Morning 9:00am - Noon Afternoon Noon - 5:00pm Evening 5:00pm - 8:00pm Would you be willing to paricipate  in in-house Testing?    In-House Testing Yes No Not Sure Do you or does anyone  in your household work for:  (check all that apply)      Yes     A food manufacturer or processor?       A food wholesaler or distributor?       An advertising or market research firm?       A newspaper, TV or radio station?         Do you do at least 50% of the grocery shopping for your household?       Do you have any food allergies such as peanuts, tree nuts (for example,  almonds, walnuts, pecans, etc.), milk or dairy products, eggs, soy, fish,  shellfish, grains or sulfiting agents?       Do you have any allergies to laundry detergents, fragrances or soaps?       Do you belong to any other Market Research panels (i.e., AC Nielsen,  Barbara Nolan, About Orlando, NFO Research)?