Thank you for you interest in participating as a Consumer Researcher at Harrisburg University of Science and Technology.

Please complete the following survey in order to enroll yourself in the database and a CIRL representative will contact you shortly.

If you have any questions about this process, please contact the CIRL at CIRL@harrisburgu.edu or (717) 901-5155.

First Name:

Last Name:

Street Address:

City:

Please enter your two character State abbreviation (Pennsylvania = PA):

Zip Code:

Email Address:

Phone Number:

Date of Birth enter as MM/DD/YYYY:

What is your gender?

MaleFemale