First Name: Last Name: Street Address:
City: State: Zip:
Email Address: Phone: Cell Phone:

Gender

 Age Marital Status:
Male Female
What level of education have
you completed?		 Income Occupation

Are you the primary decision maker for shopping in your household?
Yes No-my spouse Equal responsibility
Number of kids:  
When you go grocery shopping, how important is it to you that eco-friendly products
are offered and are easy to find?
Very Important Important Somewhat Important Not Very Important
Rate the following based on how important each item is to you and your family when you shop
 [1-not important, 2-somewhat important, 3-important, 4-very important]
Organic Vegetables/Produce
1 2 3 4
Free range chicken/beef
1 2 3 4
Hormone/drug free meat
1 2 3 4
All natural beverages
1 2 3 4
Household cleaning products
1 2 3 4
Personal hygiene products
1 2 3 4
Eco-friendly packaging
1 2 3 4
Do you find it easy to find all natural alternatives for household items like Dish Detergent, Window Cleaner etc…?
Yes No
Does pricing matter to you when making your buying decision to purchase eco-friendly products?
Yes No Sometimes
Are you willing to pay more for eco-friendly products?
Yes No If yes, how much more? %
Would you consider buying a Hybrid vehicle?
Yes No
If Yes, Why? If No, Why?
  it’s better for the environment not enough power
  gas prices are too high too small
  other I will never
        other
Which is more important to you when considering a new vehicle?
Fuel Economy
Size
Eco-Friendly
All
  other
On a scale from 1 to 10 how would you rate your household at being eco-friendly?
(1 being not eco-friendly—10 being the best you can be)
1 2 3 4 5 6 7 8 9 10
Are you interested to learn more about companies you can invest in that are environmentally conscience?
Yes No

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