www.wiltshire.gov.uk


Personal Details
Firstname *
Surname *
House name or number *
Address *
Address 1
Address 2
Town *
County *
Postcode *
Telephone *
Email
Equality Details
Please select your gender *	Male Female
Please select your age range *	18 - 24 years 25 - 34 years 35 - 44 years 45 - 54 years 55 - 64 years 65 - 74 years 75 years or over
Please select a group to which you belong *	White British White Irish White Other White & Black Caribbean White & Black African White & Asian Other Mixed Black Caribbean Other Black Pakistani Bangladeshi Other Asian Other
Please select your employment status *	Employed full time Employed part time Self Employed Looking after home or family Permanent Sick/Disabled Retired Full time Student Part time Student Unemployed
Please state your Job Title *
Please state your Industry or Business *
Please select your highest qualification *	A Level or equivalen O Level or equivalent Degree or equivalent No formal qualifications
Please select if you consider yourself to have any disability *	No Yes, affecting hearing Yes, other Yes, affecting mobility Yes, affecting vision
Please state if you or any of your household a member of the armed forces or MOD *	Yes No
Please state how many children of each age range there are living in the household
0 - 5 Years
6 - 10 Years
11 - 15 Years
16 - 18 Years
Please select your home status *	Own your own home (without a morgage) Own your own home (with a morgage) Shared ownership Rent from the Council/Housing Association Rent from a private landlord Other
Does your household own a car *	Yes No
If there is more than one car in your household, please state how many there are
If you are selected and form part of the Peoples Voice you will be given a unique reference number. You will then be able to take part in group discussions, telephone interviews etc.
Would you be willing to take part in any other forms of research? Please tick as many types of research approaches listed below that you would be willing to take part in.
I would be willing to take part in small group discussions about local community concerns *	Yes No
I would be willing to take part in further research with face to face interviews with an authorised market researcher visiting me in my home. *	Yes No
I would be willing to take part in a telephone survey *	Yes No