Date of Birth Gender Female Male

Highest Degree of Education Completed

Spouse/Partner's Occupation

Industry

Company Name Status Full-time Part-time Self-Employed Entrepreneur

Children under 18 years old living at home

Gender Female Male Date of Birth

Gender Female Male Date of Birth

Gender Female Male Date of Birth

Gender Female Male Date of Birth

Gender Female Male Date of Birth

Please list the Brand (s) of items that you own:

Automobile

Motorcycle or Scooter

Computer Printer

How do you access the internet?

Dial- Up Phone Modem Cable Modem DSL

Do you use a wireless connection? Yes No

Please check any of the following that you own or subscribe to:

Cell Phone Digital Camera Digital Camcorder Laptop Computer Handheld / PDA IPod / MP3 Player GPS Device Cable or Satellite TV

Please list any pets you own?

Do you speak any languages other than English? (Fluently) Yes No

Typically when voting - do you vote as? Republican Democrat Independent Other Not Registered

Genre most often listen to on the radio ?

Alternative Blues / Jazz Classic Rock Classical Country Hard Rock Light Rock News / Talk Oldies

Total Family Income :

Under $20,000 

$20,000-$29,999 

$30,000-$49,999

$50,000-$74,999

$75,000-$100,000

Over $100,000

Education :

High School

1 Yr. College

2 Yr. College

3 Yr. College

College Graduate

Vocational

Post Graduate

Ethnic Background :

Caucasian

Hispanic

Native American

African American

Asian

Other