First Name:

Last Name:

Street Address:

City:

State:

Zip Code:

Company Name:

Work Phone #:

Mobile Phone #:

Alternative Phone #:

Primary E-mail Address:

Secondary E-mail Address:

What is your yearly household income?

Choose One $20,000 - $50,000 $50,000 - $75,000 $750,000 - $100,000 $100,000 - $125,000 $125,000 - $150,000 Over $150,000

How many children are in the home under 18 years of age?

Choose One 0 1-2 2-3 More than 3

What is your age?

Choose One 18-25 26-35 36-45 48-55 Over 55

How many rounds of golf do you play each year?

Choose One 0-10 11-15 16-25 26-35 More than 35

Do you carry a golf handicap?

Yes / No Yes No If yes, what is it?

Are you a member of a private golf club?

Yes / No Yes No

Do you subscribe to any monthly periodicals?

Yes / No Yes No If yes, what is your favorite/s?

What are your favorite Television or radio stations?