Name:             

Telephone:           

Address:          (please include City, State & Zip)

Email:                                     

Gender:           Female     Male

Marital Status: Married     Single   If single I am engaged

Age:                                                                                                 

Church attendance: 

Regular    (one or more times per week)

Frequent  (one or more times per month)

Seldom    (several times per year)

Never      (I do not attend any church)

Home church      skip if "never"

I listen:   (Check all that apply)

  at Home

  at Work

  in Car

Time spent listening:   

1-3 times per week   4-6 times per week  

Seldom   1-3 hours per day     4-6 hours per day

I listen:                   

     Mornings                   Afternoons       

... Evenings                   Overnights        

I mainly listen to:         Programs                    Music