The Gaiam Customer Panel Application
 Thank you for your interest in becoming part of the The Gaiam Customer Panel. This is an exclusive group of Gaiam customers like you who we hope will help us shape the future of Gaiam and the products we develop. With your insights and opinions we can make better decisions that will help make a difference.
By completing this form you are agreeing that we may contact you by the methods that you choose below. We cannot guarantee you will be contacted or how often. We will decide who to contact based on the number of panel members fitting the matched profile for our survey needs.
— If you agree to be contacted by email, the survey will be a web based questionnaire you can do at home or anywhere. It will usually take 5-20 minutes and may involve watching video clips or giving feedback on designs.
— If you agree to be contacted by mail, we may ask you to review a product and give your opinions in a postage paid mail back survey.
— If you agree to be contacted by phone, we may contact you with short surveys asking your opinions.
We will only contact you via the method you specify below.

About the profile
 The following questions are to build a profile of our panel members. We do this in order to assure that we are sampling a diverse section of our customer base. We will not use this information in any way other than to select you for the appropriate survey. This will not become part of your customer profile and the database is kept completely separate. The information is not given away, traded or sold. All questions are optional, but leaving items blank may decrease the chances that you will be selected.

Rewards
 If you are selected, we will send you the invitation to the survey in the manner appropriate to that survey (mail, email or phone) and will let you know at that time what the reward (if applicable) is for completing the survey. It may be a discount, a coupon, a product or other type of reward. The rewards may have a time limit for their use and there may be additional limitations on them that will be explained within the individual survey.

Please answer the following 26 questions as truthfully as possible. Again, each question is optional, but not answering questions will decrease the odds you will be chosen for The Gaiam Customer Panel.



1. What is your age?


2. What is your gender?



3. Which of the following best represents the highest level of education that you have completed?







4. What part of the country do you live in?









5. Age of members of your household? (leave blank if not applicable)


6. Which of the following best describes your total household income before taxes last year?













7. Which of the following do you do regularly?


8. Which of the following do you do at home regularly?


9. Do you own
Yes No
VCR
DVD Player
CD Player



10. At which of these stores have you made any purchases during the past 6 months? (please check all that apply)


11. How important is it to you that.....
Very Important Not At All Important
1 2 3 4 5
The products you buy are healthy for you?
The products you buy are safe for the environment?
Companies you buy from practice environmental and social responsibility?
The products you buy are the lowest in price?



12. Rate the following sentences on a scale of Strongly Agree to Strongly Disagree
Strongly Agree Agree Neutral Disagree Strongly Disagree
I mainly shop online.
I mainly shop at larger superstores.
I research online but buy at stores.
I am a catalog shopper.
Price is my main consideration when purchasing.
Recognized brand names are important to me when purchasing.
Number of features are my main consideration when purchasing.
Product packaging plays a large role when deciding between similar products.
I watch infomercials but seldom buy.
I buy often from infomercials.
I shop mainly from natural food and vitamin stores for food.
I always look for organic goods first.
Who I buy from is as important as the product itself.
I am mainly an impulse buyer.
Trends and styles are important factors in my purchases.


13. Do you rent or own your residence?




14. Check any other interests (check all that apply):










15. What type of computer and internet user are you when it comes to:
Beginner Intermediate Experienced Power User
General Web Browsing
Online Shopping
Finding Information
Product Searching
Chat


16. Type of internet connection you have:






17. Would you be willing to take part in surveys which require you to watch a short video online?





18. Please check up to three (3) items that you would be most interested in helping Gaiam with in the future through surveys, focus groups or home testing. We may still contact you about other items.


19. Have you have purchased any of the following from Gaiam before? (Check all that apply)
















20. Do you work in the natural products industry or have special knowledge of or training in a related industry?





21. By which methods may we contact you?





22. Do you live in central Colorado (Denver/Boulder) area?




23. If you answered "Yes" to Question 22 are you willing to be contacted regarding Gaiam focus groups? This would involve 2-3 hours of your time in person (usually on weekends). The rewards for in-person groups are generally higher than web surveys. The groups would take place in the Broomfield/Boulder area.




24. Mailing Address (if you checked “by Postal Mail” in Question 21)


25. Email Address (if you checked “by Email” in Question 21)


26. Phone Number (if you checked “by Phone” in Question 21)


www.gaiam.com