Shopper Application

Please fill in the following form. All fields marked with an asterisk are required fields. If you are unable to give an answer for a required field please mark it "N/A."

The following information is necessary as it pertains to certain specifics that our clients often request when contracting our services. All information will be kept strictly confidential and will only be used to determine adherence to a specific client requirement.

Customer Service Perceptions charges an administrative processing fee of $2 to each shopper applicant. This fee in nonrefundable and does not insure that you will be accepted for inclusion in our shopper database, but that your application will be reviewed and considered for inclusion. Also, know that inclusion in our database does not guarantee you will receive an assignment, but that you will be considered for assignments that become available in your area. Customer Service Perceptions DOES NOT have shops in all areas, but as our clientele expands, so does the areas in which we shop.

Administrative Processing Fee should be sent to the following address and received by Customer Service Perceptions within 10 days of shopper's application date. If fee is received after 10 days, shopper will need to complete the application again.

Customer Service Perceptions
Attn: Application Processing
PO Box 87
Lookout Mountain, TN 37350

*If at anytime a shopper no longer wishes to be included in the CSP database, shopper must send a removal request to the above address, with attention to "Applicant Removal."

**PLEASE NOTE: Shoppers, please do not contact us regarding the availability of shops in your area. You will be notified when shops are available in your area.

Personal Information

First Name^*

Last Name^*

Address Line 1^*

Address Line 2

City^*

State^*
-- AE AK AL AR AS AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN IO KS KY LA MA MD ME MH MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY

Zip^*

County

Home Phone^*

Work Phone

Fax Number

Birthdate^*
Month January February March April May June July August September October November December   Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Race^*
-- Please Select One -- Caucasian Asian American Indian African American Hispanic Latin American Other

Gender^*
 Male
 Female

Hair Color^*
- Select - Brown Blonde Red Black Grey Other

Eye Color^*
- Select - Blue Brown Hazel Green Other

Glasses?^*
 Yes
 No

Height^*

Weight^*

Clothing Size^*
- Select - Small Medium Large X-Large Other

Body Type^*
- Select - Tall Regular Petite Plus Other

Marital Status^*
 Single
 Married
 Divorced

Child Sizes^*
If you have children,
which of the following best represents
your shopping preferences.
No Children Infants Toddlers Children Juniors Other

Do you have a pet?^*
No Pet Dog Cat Both Other

Please describe your experience as a mystery shopper, or if you do not have experience, please tell us why you would like to become a mystery shopper.^*
(300 words or less.)

Education^*
-- Please Select One -- High School Graduate Some College College Graduate Some Graduate Studies Masters/PhD Program Graduate

Name of last school attended^*

Address of last school attended^*

Work History

Profession^*

Company^*

Address Line 1^*

Address Line 2

City^*

State^*
-- AE AK AL AR AS AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN IO KS KY LA MA MD ME MH MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY

Zip^*

Position Held^*

Employed From:^*
//

Employed To:^*
//
OR check here if you are
presently employed

Income^*
-- Please Select One -- $0-$9,999 $15,000-$24,999 $25,000-$34,999 $35,000-$49,999 $50,000-$74,999 $75,000+

Please describe your duties and skills:^*

Shopping Preferences^*

Closest Major City^*

Please list all towns, cities, and communities
that you would consider shopping in:^*

Account Information

Email Address:^*

Re-enter Email Address:^*

Choose a User Name:^*

Choose a Password:^*

Re-enter Password:^*

Disclaimer - Please read carefully

Upon submission of this application you agree and understand that the information provided here is true and accurate. Applicants are independent contractors and assume all liabilities and risks which might occur while conducting mystery shops for Customer Service Perceptions and its clients. Applicants will be contacted when assignments become available in their area. Thank you for applying with Customer Service Perceptions.