Q-The Music Panel
Registration Form


Note: Federal law prevents your registration if you are under 13 years
of age. Thank you!


Simply fill in the blanks (all blanks are required) and you'll be registered to give us your opinions. It's that easy!
1
Please Select a Username (user name can only be one word)
Try to use something a little unique like your first and last name combined, your hobby, birthday, etc.
2
Please select a password
3
Your first name
4
Your last name
5
Enter your email address
6
What is your street address?
7
City
8
State
9
Your zip/postal code
10
Gender
Male
Female
11
Your birthdate
Month Day Year
12
What is your marital status? (optional)
Single, never married
Married
Divorced
Widowed
13
How many children are in your household?
14
Where do you listen to the radio MOST?
(please check only one)
Car
Home
Work
Other (please indicate where)
15
Which of these radio stations have you listened to at least
once in past week? (select any/all that apply):
Q-92
WKDD 98.1
WAKS Kiss FM 96.5
Mix 94 (94.1)
Rock 107 (106.9)
MY 101.7
Other (please indicate)
16
Which station did you listen to most in the past week? (choose only one):
Q-92
WKDD 98.1
WAKS Kiss FM 96.5
Mix 94 (94.1)
Rock 107 (106.9)
MY 101.7
Other (please indicate)
17
How much time do you spend listening to the radio
in a typical day?
1 hour or less
1-2 hours
More than 2 hours
18
What/who is your favorite artist/band?
19
Who is your favorite Q-92 DJ?
20
What do you like to do in your spare time?
(check all that apply)
Movies
TV
Sports
Pets
Reading
Computers/Internet
Other
21
What is your annual income level? (optional)
$0-$20,000
$20,001-$35,000
$35,001-$50,000
$50,001-$100,000
$100,001+
Student
22
What major purchases do you plan to make
in the next 6 months? (choose all that apply)
Automobile
Home
Jewelry
Home Electronics
Appliances
Auto Aftermarket Goods/Services
Airline Tickets
Cellular Phone/Service
Furniture
23
We just want to verify that you know you're signing up to
occasionally receive e-mail messages from us.
Note: All submitted information will remain confidential
and will not be used for any other purpose.
Yes
No