Question Catalogue Media Survey 2000
Part 1 - personalised
Forename
Surname
Date of birth
dd/mm/yy
/
/
Sex
M
F
Nationality
<Select>
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua & Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegowina
Botswana
Bouvet Island
Brazil
British Indian Ocean Terr.
Brunei Darussalam
Bulgaria
Burkina Faso
Burma (Myanmar)
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Rep
Chad
Chile
China
Christmas Island
Cocos (Keeling) Isles
Colombia
Comoros
Congo
Congo, The Democratic Rep
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
France, Metro
French Guiana
French Polynesia
French Southern Terr.
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard And Mc Donald Isles
Holy See (Vatican)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Ivory Coast (Cote D'Ivoire)
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Dem People's Rep
Korea, Republic Of
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia (Republic of)
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Fed States
Moldova, Rep
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Isles
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Kitts & Nevis
Saint Lucia
Saint Vincent & Grenadines
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leona
Singapore
Slovakia (Slovak Rep)
Slovenia
Solomon Islands
Somalia
South Africa
S Georgia & Sandwich Isles
Spain
Sri Lanka
St. Helena
St. Pierre & Miquelon
Sudan
Suriname
Svalbard & Jan Mayen Islands
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
US Minor Outlying Isles
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Isles (British)
Virgin Isles (U.S.)
Wallis & Futuna Islands
Western Sahara
Yemen
Yugoslavia
Zambia
Zimbabwe
Address
Street
Postcode
Town
Country
<Select>
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua & Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegowina
Botswana
Bouvet Island
Brazil
British Indian Ocean Terr.
Brunei Darussalam
Bulgaria
Burkina Faso
Burma (Myanmar)
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Rep
Chad
Chile
China
Christmas Island
Cocos (Keeling) Isles
Colombia
Comoros
Congo
Congo, The Democratic Rep
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
France, Metro
French Guiana
French Polynesia
French Southern Terr.
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard And Mc Donald Isles
Holy See (Vatican)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Ivory Coast (Cote D'Ivoire)
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Dem People's Rep
Korea, Republic Of
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia (Republic of)
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Fed States
Moldova, Rep
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Isles
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Kitts & Nevis
Saint Lucia
Saint Vincent & Grenadines
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leona
Singapore
Slovakia (Slovak Rep)
Slovenia
Solomon Islands
Somalia
South Africa
S Georgia & Sandwich Isles
Spain
Sri Lanka
St. Helena
St. Pierre & Miquelon
Sudan
Suriname
Svalbard & Jan Mayen Islands
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
US Minor Outlying Isles
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Isles (British)
Virgin Isles (U.S.)
Wallis & Futuna Islands
Western Sahara
Yemen
Yugoslavia
Zambia
Zimbabwe
E-Mail
@
.
Telephone
Fax
ISDN/Leo/or other
Mon adresse peut figurer dans l'annuaire des professionnels des media
Oui
Non
1 - Occupation in the last 2 years
(several answers possible)
Occupation
Full-time
Part-time
Freelance
Employed
Journalist
Print media
TV/Film
Radio
Multimedia/Web
Author
Publisher
Teacher
Scientist
Press officer
Other
If other, please specify: