Customer Feedback, LLC - Shopper InfoForm

Items with red asterisks are required.

*First Name:

Middle Name (optional):

*Last Name:

*Address:

*City:	*State:	*Zip:

*Email Address (must be the same as your PayPal email address):

*Phone:

*Date of Birth:

Mark all applicable items:

Have an airport access badge and able to get behind airport security.
Have a digital camera or camera phone.

Do you have any certifications, such as MSPA? If so, please tell us the level (Gold or Silver) and your code number:
Certification: Code Number:

Please let us know if you have been referred to us by a scheduling service.
Scheduling Service: Vendor Code:

It is important that we do not send our shoppers into businesses where a conflict of interest may exist. If you have any immediate family members who work for a major retailer (department store, drug store, etc.), bank, hotel or restaurant, please let us know:

At times, we get specific requests from clients for individuals to shop their locations in order to measure the way that different groups are treated. To assist us in meeting these requests when they occur, we would appreciate you completing the following. Completion of the following section is voluntary and is not a requirement in order to be a shopper for Customer Feedback, LLC when clients have not requested a particular type of shopper.

Disabilities:

Race:

Gender: