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Locations

MacConnell Research
One Dunwoody Park
Suite 123
Atlanta, GA 30338
Our Corporate Office is located just outside I-285 at Chamblee-Dunwoody Road.
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Cumberland Mall
Cumberland Mall is one of the largest, top-producing shopping centers in Atlanta. A pedestrian bridge connects the center with the Cobb Galleria Convention Center, which receives over 1,000,000 visitors per year.
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Application

In order for us to consider you for a survey you must complete all the information in this application that is marked by an asterisk *.

Personal Information
First Name:*
Last Name:*
Address1:*
Address2:
City:*
State:*
Zip Code:*
County:*
Home Phone:*
Work Phone:
Cell Phone:
Email Address:*
Gender:* Male   Female
Date of Birth
(mm/dd/yyyy):*		 / /
Ethnicity:
Marital Status:*
Education:*
Profession:*

Household and Vehicle Information
Household Income
(enter numbers only):		 $ .00 per year.
Do you own your home?* Yes   No
Do you own any vehicles?* Yes   No
If 'Yes', please list:  
Vehicle 1 Make:
Vehicle 1 Model:
Vehicle 1 Year:
Vehicle 2 Make:
Vehicle 2 Model:
Vehicle 2 Year:
Vehicle 3 Make:
Vehicle 3 Model:
Vehicle 3 Year:

Medical Information
Are you a diabetic? Yes   No
If 'Yes', what stage?
Are you taking any medications?* Yes   No
If 'Yes', please list: 1.
  2.
  3.

Hobbies
Do you have
any hobbies?*		 Yes   No
If 'Yes', please list: 1.
  2.
  3.

Perfumes
Do you wear
any perfumes?*		 Yes   No
If 'Yes', which brands: 1.
  2.
  3.
  4.
  5.

Pets
Do you own a
dog or cat?*		 Yes   No
If 'Yes', which brands
of dog or cat food do
you buy:		 1.
2.
3.

Children
Do you have children?* Yes   No
If 'Yes', please list:  
Child 1 First Name:
Child 1 Gender: Male   Female
Child 1 Date of Birth (mm/dd/yyyy): / /
Child 2 First Name:
Child 2 Gender: Male   Female
Child 2 Date of Birth (mm/dd/yyyy): / /
Child 3 First Name:
Child 3 Gender: Male   Female
Child 3 Date of Birth (mm/dd/yyyy): / /
Child 4 First Name:
Child 4 Gender: Male   Female
Child 4 Date of Birth (mm/dd/yyyy): / /
Child 5 First Name:
Child 5 Gender: Male   Female
Child 5 Date of Birth (mm/dd/yyyy): / /
Child 6 First Name:
Child 6 Gender: Male   Female
Child 6 Date of Birth (mm/dd/yyyy): / /

Tobacco and Alcohol
Do you smoke?* Yes   No
If 'Yes', what brand?
Do you drink alcohol?* Yes   No
If 'Yes', what brands? 1.
  2.
  3.
Do you drink wine?* Yes   No
If 'Yes', what type? Red   White   Both
If 'Yes', what brands? 1.
  2.
  3.
Do you drink beer?* Yes   No
If 'Yes', what brands? 1.
  2.
  3.
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