www.surveymonkey.com
Open in
urlscan Pro
18.66.112.88
Public Scan
Submitted URL: https://second.sisfocusgroups.com/ga/click/2-22432266-593-1766-3443-2224-a82cfe59c8-j8f68d1ad0
Effective URL: https://www.surveymonkey.com/r/CHCRZ86
Submission: On November 17 via api from US — Scanned from DE
Effective URL: https://www.surveymonkey.com/r/CHCRZ86
Submission: On November 17 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
Name: surveyForm — POST
<form name="surveyForm" action="" method="post" enctype="multipart/form-data" novalidate="" data-survey-page-form="">
<div class="questions clearfix">
<div class="question-row clearfix
">
<div data-question-type="demographic_us" data-rq-question-type="contact" class="question-container
">
<div id="question-field-87700988" data-qnumber="1" data-qdispnumber="1" data-question-id="87700988" class=" question-demographic question-demographic-us qn question us question-required">
<h3 class="screenreader-only">Question Title</h3>
<div class="text-input-group question-fieldset question-legend">
<h4 id="question-title-87700988" class=" question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 1<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> Contact Information</span>
</h4>
<div class="question-body clearfix notranslate ">
<div class="text-input-container clearfix">
<label for="87700988_687267118" class="question-body-font-theme answer-label question-demographic-label user-generated " style="width:20%;"> Name </label><input id="87700988_687267118" name="87700988_687267118" type="text"
class="text medium" size="30" aria-required="true" data-sm-open-single="" maxlength="20000">
</div>
<div class="text-input-container clearfix">
<label for="87700988_687267119" class="question-body-font-theme answer-label question-demographic-label user-generated " style="width:20%;"> Company or School </label><input id="87700988_687267119" name="87700988_687267119"
type="text" class="text medium" size="30" aria-required="true" data-sm-open-single="" maxlength="20000">
</div>
<div class="text-input-container clearfix">
<label for="87700988_687267121" class="question-body-font-theme answer-label question-demographic-label user-generated " style="width:20%;"> Linkedin profile Link or another Social Media profile Link (Mandatory - for verification
purposes only) </label><input id="87700988_687267121" name="87700988_687267121" type="text" class="text medium" size="30" aria-required="true" data-sm-open-single="" maxlength="20000">
</div>
<div class="text-input-container clearfix">
<label for="87700988_687267122" class="question-body-font-theme answer-label question-demographic-label user-generated " style="width:20%;"> City/Town </label><input id="87700988_687267122" name="87700988_687267122" type="text"
class="text medium" size="15" aria-required="true" data-sm-open-single="" maxlength="20000">
</div>
<div class="text-input-container clearfix">
<label for="87700988_687267123" class="question-body-font-theme answer-label question-demographic-label user-generated " style="width:20%;"> State/Province </label><select id="87700988_687267123" class="select"
name="87700988_687267123">
<option value="">-- select state --</option>
<option value="AL">AL Alabama</option>
<option value="AK">AK Alaska</option>
<option value="AS">AS American Samoa</option>
<option value="AZ">AZ Arizona</option>
<option value="AR">AR Arkansas</option>
<option value="CA">CA California</option>
<option value="CO">CO Colorado</option>
<option value="CT">CT Connecticut</option>
<option value="DE">DE Delaware</option>
<option value="DC">DC District of Columbia</option>
<option value="FM">FM Federated States of Micronesia</option>
<option value="FL">FL Florida</option>
<option value="GA">GA Georgia</option>
<option value="GU">GU Guam</option>
<option value="HI">HI Hawaii</option>
<option value="ID">ID Idaho</option>
<option value="IL">IL Illinois</option>
<option value="IN">IN Indiana</option>
<option value="IA">IA Iowa</option>
<option value="KS">KS Kansas</option>
<option value="KY">KY Kentucky</option>
<option value="LA">LA Louisiana</option>
<option value="ME">ME Maine</option>
<option value="MH">MH Marshall Islands</option>
<option value="MD">MD Maryland</option>
<option value="MA">MA Massachusetts</option>
<option value="MI">MI Michigan</option>
<option value="MN">MN Minnesota</option>
<option value="MS">MS Mississippi</option>
<option value="MO">MO Missouri</option>
<option value="MT">MT Montana</option>
<option value="NE">NE Nebraska</option>
<option value="NV">NV Nevada</option>
<option value="NH">NH New Hampshire</option>
<option value="NJ">NJ New Jersey</option>
<option value="NM">NM New Mexico</option>
<option value="NY">NY New York</option>
<option value="NC">NC North Carolina</option>
<option value="ND">ND North Dakota</option>
<option value="MP">MP Northern Mariana Islands</option>
<option value="OH">OH Ohio</option>
<option value="OK">OK Oklahoma</option>
<option value="OR">OR Oregon</option>
<option value="PW">PW Palau</option>
<option value="PA">PA Pennsylvania</option>
<option value="PR">PR Puerto Rico</option>
<option value="RI">RI Rhode Island</option>
<option value="SC">SC South Carolina</option>
<option value="SD">SD South Dakota</option>
<option value="TN">TN Tennessee</option>
<option value="TX">TX Texas</option>
<option value="UT">UT Utah</option>
<option value="VT">VT Vermont</option>
<option value="VI">VI Virgin Islands</option>
<option value="VA">VA Virginia</option>
<option value="WA">WA Washington</option>
<option value="WV">WV West Virginia</option>
<option value="WI">WI Wisconsin</option>
<option value="WY">WY Wyoming</option>
</select>
</div>
<div class="text-input-container clearfix">
<label for="87700988_687267125" class="question-body-font-theme answer-label question-demographic-label user-generated " style="width:20%;"> Country </label><input id="87700988_687267125" name="87700988_687267125" type="text"
class="text medium" size="15" aria-required="true" data-sm-open-single="" maxlength="20000">
</div>
<div class="text-input-container clearfix">
<label for="87700988_687267126" class="question-body-font-theme answer-label question-demographic-label user-generated " style="width:20%;"> Email Address </label><input id="87700988_687267126" name="87700988_687267126" type="email"
class="text medium" size="30" aria-required="true" data-sm-open-single="" maxlength="20000">
</div>
<div class="text-input-container clearfix">
<label for="87700988_687267127" class="question-body-font-theme answer-label question-demographic-label user-generated " style="width:20%;"> Phone Number </label><input id="87700988_687267127" name="87700988_687267127" type="tel"
class="text medium" size="30" aria-required="true" data-sm-open-single="" maxlength="20000">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="question-row clearfix
">
<div data-question-type="open_ended_single" data-rq-question-type="open_ended" class="question-container
">
<div id="question-field-87696914" data-qnumber="2" data-qdispnumber="2" data-question-id="87696914" class=" question-open-ended-single qn question single question-required">
<h3 class="screenreader-only">Question Title</h3>
<div class=" question-fieldset question-legend">
<h4 id="question-title-87696914" class=" question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 2<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> What is your age?</span>
</h4>
<div class="question-body clearfix notranslate ">
<div id="open-ended-single_87696914" data-question-id="87696914" data-response="" data-sm-open-single="" maxlength="20000" data-ng="true" data-required="true" data-size="50" data-labeledby="question-title-87696914">
<div class="question-body open-ended-single"><input aria-labelledby="question-title-87696914" id="87696914" aria-required="true" data-sm-open-single="true" maxlength="20000" class="wds-input wds-input--lg qt-input_text text"
name="87696914" size="50" value=""></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="question-row clearfix
">
<div data-question-type="single_choice_menu" data-rq-question-type="dropdown" class="question-container
">
<div id="question-field-89102127" data-qnumber="3" data-qdispnumber="3" data-question-id="89102127" class=" question-single-choice-select qn question menu question-required">
<h3 class="screenreader-only">Question Title</h3>
<fieldset class=" question-fieldset">
<legend class="question-legend">
<h4 id="question-title-89102127" class="
question-title-container ">
<span class="required-asterisk notranslate"> * </span>
<span class="question-number notranslate"> 3<span class="question-dot">.</span>
</span>
<span class="user-generated notranslate
"> Where were you born?</span>
</h4>
</legend>
<div class="question-body clearfix notranslate ">
<select id="89102127" name="89102127" aria-labelledby="question-title-89102127" class="select no-touch" data-sm-select="">
<option value=""></option>
<option value="696923655" class="user-generated"> Afghanistan </option>
<option value="696923656" class="user-generated"> Albania </option>
<option value="696923657" class="user-generated"> Algeria </option>
<option value="696923658" class="user-generated"> Andorra </option>
<option value="696923659" class="user-generated"> Angola </option>
<option value="696923660" class="user-generated"> Anguilla </option>
<option value="696923661" class="user-generated"> Antigua and Barbuda </option>
<option value="696923662" class="user-generated"> Argentina </option>
<option value="696923663" class="user-generated"> Armenia </option>
<option value="696923664" class="user-generated"> Australia </option>
<option value="696923665" class="user-generated"> Austria </option>
<option value="696923666" class="user-generated"> Azerbaijan </option>
<option value="696923667" class="user-generated"> Bahamas </option>
<option value="696923668" class="user-generated"> Bahrain </option>
<option value="696923669" class="user-generated"> Bangladesh </option>
<option value="696923670" class="user-generated"> Barbados </option>
<option value="696923671" class="user-generated"> Belarus </option>
<option value="696923672" class="user-generated"> Belgium </option>
<option value="696923673" class="user-generated"> Belize </option>
<option value="696923674" class="user-generated"> Benin </option>
<option value="696923675" class="user-generated"> Bhutan </option>
<option value="696923676" class="user-generated"> Bolivia (Plurinational State of) </option>
<option value="696923677" class="user-generated"> Bosnia and Herzegovina </option>
<option value="696923678" class="user-generated"> Botswana </option>
<option value="696923679" class="user-generated"> Brazil </option>
<option value="696923680" class="user-generated"> British Virgin Island </option>
<option value="696923681" class="user-generated"> Brunei Darussalam </option>
<option value="696923682" class="user-generated"> Bulgaria </option>
<option value="696923683" class="user-generated"> Burkina Faso </option>
<option value="696923684" class="user-generated"> Burundi </option>
<option value="696923685" class="user-generated"> Cabo Verde </option>
<option value="696923686" class="user-generated"> Cambodia </option>
<option value="696923687" class="user-generated"> Cameroon </option>
<option value="696923688" class="user-generated"> Canada </option>
<option value="696923689" class="user-generated"> Cayman Islands </option>
<option value="696923690" class="user-generated"> Central African Republic </option>
<option value="696923691" class="user-generated"> Chad </option>
<option value="696923692" class="user-generated"> Chile </option>
<option value="696923693" class="user-generated"> China </option>
<option value="696923694" class="user-generated"> Colombia </option>
<option value="696923695" class="user-generated"> Comoros </option>
<option value="696923696" class="user-generated"> Congo </option>
<option value="696923697" class="user-generated"> Costa Rica </option>
<option value="696923698" class="user-generated"> Côte D'Ivoire </option>
<option value="696923699" class="user-generated"> Croatia </option>
<option value="696923700" class="user-generated"> Cuba </option>
<option value="696923701" class="user-generated"> Cyprus </option>
<option value="696923702" class="user-generated"> Czech Republic </option>
<option value="696923703" class="user-generated"> Democratic People's Republic of Korea </option>
<option value="696923704" class="user-generated"> Democratic Republic of the Congo </option>
<option value="696923705" class="user-generated"> Denmark </option>
<option value="696923706" class="user-generated"> Djibouti </option>
<option value="696923707" class="user-generated"> Dominica </option>
<option value="696923708" class="user-generated"> Dominican Republic </option>
<option value="696923709" class="user-generated"> Ecuador </option>
<option value="696923710" class="user-generated"> Egypt </option>
<option value="696923711" class="user-generated"> El Salvador </option>
<option value="696923712" class="user-generated"> Equatorial Guinea </option>
<option value="696923713" class="user-generated"> Eritrea </option>
<option value="696923714" class="user-generated"> Estonia </option>
<option value="696923715" class="user-generated"> Ethiopia </option>
<option value="696923716" class="user-generated"> Fiji </option>
<option value="696923717" class="user-generated"> Finland </option>
<option value="696923718" class="user-generated"> France </option>
<option value="696923719" class="user-generated"> Gabon </option>
<option value="696923720" class="user-generated"> Gambia </option>
<option value="696923721" class="user-generated"> Georgia </option>
<option value="696923722" class="user-generated"> Germany </option>
<option value="696923723" class="user-generated"> Ghana </option>
<option value="696923724" class="user-generated"> Greece </option>
<option value="696923725" class="user-generated"> Grenada </option>
<option value="696923726" class="user-generated"> Guatemala </option>
<option value="696923727" class="user-generated"> Guinea </option>
<option value="696923728" class="user-generated"> Guinea Bissau </option>
<option value="696923729" class="user-generated"> Guyana </option>
<option value="696923730" class="user-generated"> Haiti </option>
<option value="696923731" class="user-generated"> Holy See </option>
<option value="696923732" class="user-generated"> Honduras </option>
<option value="696923733" class="user-generated"> Hungary </option>
<option value="696923734" class="user-generated"> Iceland </option>
<option value="696923735" class="user-generated"> India </option>
<option value="696923736" class="user-generated"> Indonesia </option>
<option value="696923737" class="user-generated"> Iran (Islamic Republic of) </option>
<option value="696923738" class="user-generated"> Iraq </option>
<option value="696923739" class="user-generated"> Ireland </option>
<option value="696923740" class="user-generated"> Israel </option>
<option value="696923741" class="user-generated"> Italy </option>
<option value="696923742" class="user-generated"> Jamaica </option>
<option value="696923743" class="user-generated"> Japan </option>
<option value="696923744" class="user-generated"> Jordan </option>
<option value="696923745" class="user-generated"> Kazakhstan </option>
<option value="696923746" class="user-generated"> Kenya </option>
<option value="696923747" class="user-generated"> Kiribati </option>
<option value="696923748" class="user-generated"> Kuwait </option>
<option value="696923749" class="user-generated"> Kyrgyzstan </option>
<option value="696923750" class="user-generated"> Lao People’s Democratic Republic </option>
<option value="696923751" class="user-generated"> Latvia </option>
<option value="696923752" class="user-generated"> Lebanon </option>
<option value="696923753" class="user-generated"> Lesotho </option>
<option value="696923754" class="user-generated"> Liberia </option>
<option value="696923755" class="user-generated"> Libya </option>
<option value="696923756" class="user-generated"> Liechtenstein </option>
<option value="696923757" class="user-generated"> Lithuania </option>
<option value="696923758" class="user-generated"> Luxembourg </option>
<option value="696923759" class="user-generated"> Madagascar </option>
<option value="696923760" class="user-generated"> Malawi </option>
<option value="696923761" class="user-generated"> Malaysia </option>
<option value="696923762" class="user-generated"> Maldives </option>
<option value="696923763" class="user-generated"> Mali </option>
<option value="696923764" class="user-generated"> Malta </option>
<option value="696923765" class="user-generated"> Marshall Islands </option>
<option value="696923766" class="user-generated"> Mauritania </option>
<option value="696923767" class="user-generated"> Mauritius </option>
<option value="696923768" class="user-generated"> Mexico </option>
<option value="696923769" class="user-generated"> Micronesia (Federated States of) </option>
<option value="696923770" class="user-generated"> Monaco </option>
<option value="696923771" class="user-generated"> Mongolia </option>
<option value="696923772" class="user-generated"> Montenegro </option>
<option value="696923773" class="user-generated"> Montserrat </option>
<option value="696923774" class="user-generated"> Morocco </option>
<option value="696923775" class="user-generated"> Mozambique </option>
<option value="696923776" class="user-generated"> Myanmar </option>
<option value="696923777" class="user-generated"> Namibia </option>
<option value="696923778" class="user-generated"> Nauru </option>
<option value="696923779" class="user-generated"> Nepal </option>
<option value="696923780" class="user-generated"> Netherlands </option>
<option value="696923781" class="user-generated"> New Zealand </option>
<option value="696923782" class="user-generated"> Nicaragua </option>
<option value="696923783" class="user-generated"> Niger </option>
<option value="696923784" class="user-generated"> Nigeria </option>
<option value="696923785" class="user-generated"> Norway </option>
<option value="696923786" class="user-generated"> Oman </option>
<option value="696923787" class="user-generated"> Pakistan </option>
<option value="696923788" class="user-generated"> Palau </option>
<option value="696923789" class="user-generated"> Panama </option>
<option value="696923790" class="user-generated"> Papua New Guinea </option>
<option value="696923791" class="user-generated"> Paraguay </option>
<option value="696923792" class="user-generated"> Peru </option>
<option value="696923793" class="user-generated"> Philippines </option>
<option value="696923794" class="user-generated"> Poland </option>
<option value="696923795" class="user-generated"> Portugal </option>
<option value="696923796" class="user-generated"> Qatar </option>
<option value="696923797" class="user-generated"> Republic of Korea </option>
<option value="696923798" class="user-generated"> Republic of Moldova </option>
<option value="696923799" class="user-generated"> Romania </option>
<option value="696923800" class="user-generated"> Russian Federation </option>
<option value="696923801" class="user-generated"> Rwanda </option>
<option value="696923802" class="user-generated"> Saint Kitts and Nevis </option>
<option value="696923803" class="user-generated"> Saint Lucia </option>
<option value="696923804" class="user-generated"> Saint Vincent and the Grenadines </option>
<option value="696923805" class="user-generated"> Samoa </option>
<option value="696923806" class="user-generated"> San Marino </option>
<option value="696923807" class="user-generated"> Sao Tome and Principe </option>
<option value="696923808" class="user-generated"> Saudi Arabia </option>
<option value="696923809" class="user-generated"> Senegal </option>
<option value="696923810" class="user-generated"> Serbia </option>
<option value="696923811" class="user-generated"> Seychelles </option>
<option value="696923812" class="user-generated"> Sierra Leone </option>
<option value="696923813" class="user-generated"> Singapore </option>
<option value="696923814" class="user-generated"> Slovakia </option>
<option value="696923815" class="user-generated"> Slovenia </option>
<option value="696923816" class="user-generated"> Solomon Islands </option>
<option value="696923817" class="user-generated"> Somalia </option>
<option value="696923818" class="user-generated"> South Africa </option>
<option value="696923819" class="user-generated"> South Sudan </option>
<option value="696923820" class="user-generated"> Spain </option>
<option value="696923821" class="user-generated"> Sri Lanka </option>
<option value="696923822" class="user-generated"> State of Palestine </option>
<option value="696923823" class="user-generated"> Sudan </option>
<option value="696923824" class="user-generated"> Suriname </option>
<option value="696923825" class="user-generated"> Swaziland </option>
<option value="696923826" class="user-generated"> Sweden </option>
<option value="696923827" class="user-generated"> Switzerland </option>
<option value="696923828" class="user-generated"> Syrian Arab Republic </option>
<option value="696923829" class="user-generated"> Tajikistan </option>
<option value="696923830" class="user-generated"> Thailand </option>
<option value="696923831" class="user-generated"> The former Yugoslav Republic of Macedonia </option>
<option value="696923832" class="user-generated"> Timor-Leste </option>
<option value="696923833" class="user-generated"> Togo </option>
<option value="696923834" class="user-generated"> Tonga </option>
<option value="696923835" class="user-generated"> Trinidad and Tobago </option>
<option value="696923836" class="user-generated"> Tunisia </option>
<option value="696923837" class="user-generated"> Turkey </option>
<option value="696923838" class="user-generated"> Turkmenistan </option>
<option value="696923839" class="user-generated"> Turks and Caicos </option>
<option value="696923840" class="user-generated"> Tuvalu </option>
<option value="696923841" class="user-generated"> Uganda </option>
<option value="696923842" class="user-generated"> Ukraine </option>
<option value="696923843" class="user-generated"> United Arab Emirates </option>
<option value="696923844" class="user-generated"> United Kingdom of Great Britain and Northern Ireland </option>
<option value="696923845" class="user-generated"> United Republic of Tanzania </option>
<option value="696923846" class="user-generated"> United States of America </option>
<option value="696923847" class="user-generated"> Uruguay </option>
<option value="696923848" class="user-generated"> Uzbekistan </option>
<option value="696923849" class="user-generated"> Vanuatu </option>
<option value="696923850" class="user-generated"> Venezuela (Bolivarian Republic of) </option>
<option value="696923851" class="user-generated"> Vietnam </option>
<option value="696923852" class="user-generated"> Yemen </option>
<option value="696923853" class="user-generated"> Zambia </option>
<option value="696923854" class="user-generated"> Zimbabwe </option>
</select>
</div>
</fieldset>
</div>
</div>
</div>
</div>
<div class="survey-submit-actions center-text clearfix">
<button type="submit" data-submit-page-button="" class="btn small next-button survey-page-button user-generated notranslate"> Next </button>
</div>
<input type="hidden" id="survey_data" name="survey_data"
value="4FoTYerhlqpl9PSGmuD5IYoYPN7pAf03nQrqpR_2F17j5egatkWBvu8_2Bl6_2F56lvCq6fQU9Mwg9Na2g5U2u5PzQtbhzWokN7CFs1lVdGWqVRcGv7M1swQnKcRE_2BV8wjXf0WIuJvPEReKV5P9z2KmOarFYbcWl0CrLzIoI0KxtsQHkqR5R9zp_2FPdiRdZYhFW6789eQPwhohQ8hphAE0oTJ4GjakNX8LPtsb2GCiLqScjzESxqV5Pvo8iHHFX7CHkzbXcvHES_2FgQyFd7kW6dYc2NqDi4ZwWX6EZBYY6GjxkDMc2Dt6_2BYH2918NWMg7kB6TgIW4siqJhVVOn44xEkLppDCunUo_2Fwaw03a8ne_2B0e4B7jDNO0LfE0l64RT6ead5_2BlErnllQBoR5K4DvMbj1XuRydk7rtHFUHqQAXF3HXZz3YDM2CtrWjjibbdCeUp7RNySqxJqldAl8fpQimGp1x_2BdJr_2BGrw1i3gOwTTAMoed5UKu3D6QwQIPdgd6yvbrIPMF4sf5PdtkOUIFItDsiBtHz1y24BtVKjY_2FTM5E7ph1Atpt7Qmz3tx4meNXdbMUngpUTqp">
<input type="hidden" data-response-quality="" id="response_quality_data" name="response_quality_data" value="{}">
<input type="hidden" id="is_previous" name="is_previous" value="false">
<input type="hidden" id="disable_survey_buttons_on_submit" name="disable_survey_buttons_on_submit" value="">
</form>Text Content
CONSUMER FOCUS GROUP WITH PORTUGUESE IMMIGRANTS IN THE USA PRE-SCREENER TO BE CONSIDERED SIS Research is conducting an online Focus Group with Portuguese emigrants and descendants. We are providing $150 compensation for those who qualify, are selected, and complete an approximately 2-hour online Focus Group. We are interested to understand opinions and perceptions about beverage consumption and drinking habits. This fun and lively session will be entirely online. All content is confidential and for research purposes only. If you’re interested, we would first like to see if this research is a fit. Please take the pre-screener below to be considered. Your privacy is important for us. We will not share your personal data with a third party and will only use it for the purpose of this research. QUESTION TITLE * 1. CONTACT INFORMATION Name Company or School Linkedin profile Link or another Social Media profile Link (Mandatory - for verification purposes only) City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming Country Email Address Phone Number QUESTION TITLE * 2. WHAT IS YOUR AGE? QUESTION TITLE * 3. WHERE WERE YOU BORN? Afghanistan Albania Algeria Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia (Plurinational State of) Bosnia and Herzegovina Botswana Brazil British Virgin Island Brunei Darussalam Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Côte D'Ivoire Croatia Cuba Cyprus Czech Republic Democratic People's Republic of Korea Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea Bissau Guyana Haiti Holy See Honduras Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Lao People’s Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia (Federated States of) Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Republic of Korea Republic of Moldova Romania Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka State of Palestine Sudan Suriname Swaziland Sweden Switzerland Syrian Arab Republic Tajikistan Thailand The former Yugoslav Republic of Macedonia Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Tuvalu Uganda Ukraine United Arab Emirates United Kingdom of Great Britain and Northern Ireland United Republic of Tanzania United States of America Uruguay Uzbekistan Vanuatu Venezuela (Bolivarian Republic of) Vietnam Yemen Zambia Zimbabwe Next Powered by See how easy it is to create a survey. Privacy & Cookie Notice Javascript is required for this site to function, please enable.