Q-Card Application

To receive your Country Q-Card please fill out the form below. You will need to fill out this form in its entirety in order for your card to be processed.

Name:	Male Female
Email:
Address:
City:
State:	Zip:
Phone:
Fax:	May we fax you about future events? Yes No
Date of Birth:	Marital Status: Single Married
How many people, including yourself, live in your household? 1 2 3 4 5+
If you have children, what are their ages? Under 5 6 - 13 Over 13

What is your occupation/profession?
Sales Professional Clerical/Office worker Manager/Proprietor Laborer	Education Student Homemaker Other

How many hours per week do you listen to radio?
Less than 1 1-3 3-5	5-10 More than 10

When do you listen to Q106?

Weekdays:
Mornings 5:30am - 10am
Middays 10am - -2:30pm
Afternoons 2:30pm - 7:00pm
Evenings 7:00pm - midnight
Overnights

Saturdays:
Mornings 5:30am - 10am
Middays 10am - -2:30pm
Afternoons 2:30pm - 7:00pm
Evenings 7:00pm - midnight
Overnights

Sundays:
Mornings 5:30am - 10am
Middays 10am - 2:30pm
Afternoons 2:30pm - 7:00pm
Evenings 7:00pm - midnight
Overnights

What other stations do you listen to?
FM 88.7 WERN 92.1 WMAD-FM 94.1 WJJO 94.9 WOLX 96.3 WMLI 98.1 WMGN 101.5 WIBA-FM 102.5 WNWC 104.1 WZEE 105.1 WYZM 105.5 WMMM	AM 97O WHA 1070 WTSO 1310 WIBA 1550 WHIT 1670 WTDY

What is your household income?
Under $25,000 $25-$39,999 $40-$54,999	$55-$74,999 Over $75,000

Which activities do you participate in?
Bicycling Bowling Fishing Hunting Running Downhill skiing Boating Camping Golf	Tennis Softball Volleyball X-country skiing Gardening Hiking/Walking In-line skating Working out Shopping

What consumer electronic equipment/service(s) does your household have?
CD Player CD-ROM Reader Premium Cable TV Basic Cable TV Computer Modem Home Entertainment Center

Does your household have a personal computer?
Macintosh DOS-based	Windows-based

What computer service(s) do you subscribe to?
America On-line Internet	CompuServe Prodigy GEnie

How many vacations or trips do you take each year?
Less than 1 1-2 3-4 5+

What types of vacation destinations do you prefer?
Florida California Hawaii Mexico Caribbean Mediterranean Eastern U.S.	Vegas/Atlantic City Europe Asia Australia/ Pacific Ocean Africa Northwoods Western U.S.

How often do you travel with children?
Never Occasionally Half the time	Most of the time Always

Thank You!

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