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Phoenix, AZ
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Email
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Your email
First Name
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Your answer
Last Name
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Your answer
Phone Number
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Your answer
Age
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Your answer
Gender
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Female
Male
Non-Binary
Prefer not to say
Ethnicity
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African American
Asian
Caucasian
Hispanic
Other
Highest Level of Education Completed
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Less than High School
High School/GED
Some College/Trade
Associate Degree
Bachelors Degree
Post Grad/Masters
Employment Status
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Part Time
Full Time
Self Employed
Full Time Student (Employed)
Full Time Student (Unemployed)
Unemployed
Homemaker
Retired
What is your current occupation? (please list previous if unemployed, homemaker or retired)
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Your answer
What industry do you work in? (please list previous if unemployed, homemaker or retired)
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Your answer
Annual Household Income
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<$25K
$25,000-$50,000
$50,000-$75,000
$75,000-$100,000
$100,000-$150,000
$150,000-$200,000
>$200K
What CITY Do you live in?
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Your answer
What COUNTY do you live in?
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Your answer
What is your ZIP CODE?
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Your answer
How would you describe the area in which you live?
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Metropolitan
Suburban
Rural
Do you have a valid Drivers Licence?
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Yes
No
Do you own your own vehicle?
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Yes
No
What year is your vehicle? (ex; 2017, 2018, 2019)
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Your answer
What is the MAKE of your vehicle? (ex; Ford, Mercedes, BMW)
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Your answer
What MODEL is your vehicle? (ex; Explorer, E-Class, 4 Series)
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Your answer
What other vehicles do you have in your household? (ex; 2014 Ford Focus, 2017 Honda Civic)
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Your answer
Does your vehicle have Speed and Distance Assistance/Adaptive Cruise Control?
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Yes
No
Does your vehicle have Steering and Lane Keeping Assistance?
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Yes
No
Does your vehicle have Active Distance Assist DISTRONIC/DISTRONIC PLUS?
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Yes
No
Does your vehicle have Active Lane Keeping Assist?
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Yes
No
Does your vehicle have Autopilot?
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Yes
No
Does your vehicle have Super Cruise?
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Yes
No
We will require proof of ownership, if selected. We will ask for a picture of your registration and/or insurance with your name a vehicle listed on it. Is this something that you can provide?
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Yes
No
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