First Name
Last Name:
Email Address:
Your Email Address Again: (for verification)
Your secondary Email Address
Street Address:
City:
State/Prov:
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip/Postal Code:
Home Phone-Required (ie 555
555-5555 for all numbers listed)
Work Phone:
Cell Phone
Can we contact you at work?
YES
NO
How did you hear about us?
Online Classified
Online Job Posting
Banner Ad
Yahoo
Alta Vista
Excite
MSN
AOL
Goto.com
Dogpile
Newspaper Classified Ad
Friend/Relative
Radio or T.V.
Link from another page
Other
If "Other", please specify:
If referred, please give name
If you do not supply the requested information below, you may not
qualify for some shops.
Some of our clients require specific demographics and the only way
for us to identify you as
matching those requirements is through the information you
provide. The more information
you provide, the more likely you will qualify for one of these
shops.
Demographic Information
Gender
Female
Male
Date of Birth (MM/DD/YYYY)
You must be at least 21 years old to apply to become a mystery
shopper. Falsifying this information could possibly lead to
serious repercussions and liability in the event of a problem.
Marital Status
Never Married
Married
Divorced
Widowed
Occupation
Professional
Retail
Sales
Homemaker
Manufacturing/Skilled Labor
Student
Retired
Unemployed
Other
Mystery Shopper
Household Income Range
Less Than $20,000 Per Year
$20,001 to $35,000 Per Year
$35,001 to $50,000 Per Year
$50,001 to $75,000 Per Year
$75,001 to $100,000 Per Year
$100,001 to $200,000 Per Year
Over $200,000 Per Year
Mystery Shopping Experience
None
Restaurants
Hotels
Retail
Apartments
Automotive
Banks
Several Types
Other
Availability
Anytime
Days
Evenings
Late Night
Weekends
How many times per month do you eat at
fast food restaurants?
0-3
4-7
8-12
More than 12
How many times per month do you eat at
casual dining restaurants?
0-3
4-7
8-12
More than 12
How many times per month do you eat at
fine dining restaurants?
0-3
4-7
8-12
More than 12
What type of computer do you have access
to?
Windows Compatible
Macintosh/Apple
Other
None
Do you have a web-enabled PDA?
Yes
No
If you have a cell phone, indicate what
type:
Cell Phone Only
Cell Phone With Internet Access
Do you have a cell phone or PDA with
photo capability?
Yes
No
Do you have a digital camera?
Yes
No
Do you have a document/photo scanner?
Yes
No
Do you have a fax machine?
Yes
No
Indicate your ethno cultural heritage:
African American or Black
Asian
Caucasian or White
Middle Eastern
Native American or Alaska Native
Pacific Islander
Other
What color is your hair?
Auburn
Black
Blonde
Brown
Gray
Red
Strawberry Blonde
Other
What color are your eyes?
Blue
Brown
Gray
Green
Hazel
Other
Indicate if you wear glasses/contacts:
Glasses - corrected far vision
Glasses - corrected near vision
Glasses - reading only
Contacts - corrected far vision
Contacts - corrected near vision
Indicate which best describes your handedness:
Right-handed
Left-handed
Ambidextrous
Indicate which best describes your body
type:
Tall, slim build
Tall, medium build
Tall, large build
Average height, slim build
Average height, medium build
Average height, large build
Short, slim build
Short, medium build
Short, large build
Indicate any disability you may have:
Blind
Deaf
Missing Limb
Wheel Chair
Other
Do you own or rent your home?
Own
Rent
How many children do you have (use 9 if
9 or more)?
0
1
2
3
4
5
6
7
8
9
What type of vehicle is your primary
transportation?
Car
Minivan
Motorcyle
Sport Utility
Truck
Van
Other
How many active credit cards do you have
(use 9 if 9 or more)?
0
1
2
3
4
5
6
7
8
9
Are you a qualified registered voter?
Yes
No
What languages do you speak?
(Select multiple languages by holding down "Ctrl"
key.)
English
French
Spanish
German
Italian
Japanese
Cantonese
Mandarin
Education
Level of Education:
High School
Diploma / Certificate
Bachelor
Master /
Professional Degree
Ph.D.
Other
If not listed, please specify:
Current Employment
Briefly describe your current job:
Industry:
Title:
Duties:
If you are a member of Mystery Shopping Providers Association
(MSPA)
please provide your Certification level.
MSPA Certification Level:
Silver
Gold
MSPA Certification Number:
If Mystery Shopping
Experience, Which Companies?
Briefly describe any
experience that you feel would make you a good Secret Shopper.
Recent Shop Essay
Mystery shopping requires you to describe and detail your shopping
experience. In order for us to qualify you as a shopper, please
provide an example of your experience. Please describe your
last casual or fine dining restaurant, retail, or other
experience. In order to better 'match' the shopper with specific
assignments, your narrative is evaluated with respect to spelling,
punctuation, and quality of your content.