Respondent Sign-Up Form
Todays Date/Year (*)

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First Name (*)

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Last Name (*)

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Month/Year of Birth (*)

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Address (*)

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City (*)

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State (*)

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Zip Code (*)

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Nighttime Phone Number (*)

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Cell Phone Number

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Email Address (*)

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Occupation and Type of Business you work for (*)

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Marital Status (*)





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If married, is your spouse interested as well? (*)

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Spouse's Name

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Spouse's month/year of Birth

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Spouse's phone number (if different from yours)

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Spouse's Occupation and Type of business works for

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Spouse's email

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Do you have children in your household? (*)

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If yes, please list your children's sex and month/year of birth. (i.e. Male-July/1998 or Female-November/2003)

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Select your favorite radio station (*)

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Your second favorite station (*)

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Your spouse's favorite station

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Your spouse's second favorite station

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Please list your households vehicles: (i.e. 2011 Ford Explorer)

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Do you have a cat? (*)

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Do you have a dog? (*)

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Do you have cable tv? (*)

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Do you have satellite tv? (*)

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Do you have a cellphone? (*)

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If you have a cellphone, please list the company that provides your cellular service

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Do you have a computer? (*)

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Do you have broadband/high speed internet? (*)

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Do you have a boat? (*)

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Do you have a snowmobile? (*)

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If you smoke, please indicate your brand. Please be specific about size, strength, etc. (i.e. Marlboro Light 100, Camel Ultra Light Kings)

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If your spouse smokes, please indicate their brand

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Select your race (*)







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Select your household income (*)

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Do you own your own home or do you rent? (*)

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Select your education level (*)

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Your spouse's education level

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Please indicate how you were referred to us (*)

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If referred by or given a flyer from a person please enter their name

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720 Thomas Lane              Brookfield, WI 53005                262-938-9244