Questionnaire Text

Questionnaire form view entire document: text image

For all persons aged 14 or older

If have practice a professional activity, answer questions 12 through 15,
Including: If you help a family member at work, even if part time
If you are an apprentice under contract or a paid intern

If you are not currently practice a professional activity or if you are unemployed: answer question 16.

14. Where do you work?

a. Work address:
Street Number ____
Street or place name [lieudit] ____
Town or city and state [département] ____
(For Paris, Lyon and Marseille, indicate the district within the city [arrondissement])

b. Name (or corporate name) of establishment (industrial, commercial, administrative, agricultural, etc.) which employs you or which you direct: ____

c. Activity of the business:
Be specific. Examples include: Wholesale wine dealer, metal framework manufacture, cotton spinning, supplier of overland transportation for travelers, etc.

d. Address of the business, if different than stated above in question 14a:
Street Number ____
Street or place name [lieudit] ____
Town or city and state [département] ____
(For Paris, Lyon and Marseille, indicate the district within the city [arrondissement])