Maryland Marketing Source, Inc.

Address 1:

Address 2:

City:

State:

Zip:

Home Phone:  *

Cell Phone

Work Phone Number

E-mail:

Gender: Select One  Male  Female 

Race: Select One  African American  Asian  Caucasian  Hispanic/Latino  Native American 

Year Born:

Do you Smoke:  Yes   No 

If Yes, what Brand:

Do you Drive:  Yes   No 

Education level: Select One  0-8th Grade  Some High School  High School  Trade School  Some College  Associate's Degree  Bachelor's Degree  Post. Grad. Degree 

Occupation & Industry:

Favorite radio stations:

Political affiliation: Select One  Democrat  Republican  Independent 

Marital Status Select One  Married  Single  Widowed  Divorced 

Year child 1 born

Child 1 Gender  Male   Female 

Year child 2 born

Child 2 Gender  Male   Female 

Year child 3 born

Child 3 Gender  Male   Female 

Year child 4 born

Child 4 Gender  Male   Female 

Spouse Name (if interested):

Spouse's Gender Select One  Male  Female 

Spouse cell phone number

Spouse work phone number

Spouse's Email:

Spouse Race Select One  African American  Asian  Caucasian  Hispanic/Latino  Native American 

Year spouse Born

Do spouse Smoke:  Yes   No 

If Yes, what Brand?

Do spouse Drive:  Yes   No 

Spouse education level: 0-8th Grade  Some High School  High School  Trade School  Some College  Associate's Degree  Bachelor's Degree  Post Grad. Degree  Select One 

Spouse Occupation & Indusry:

Spouse favorite radio stations:

Spouse political affiliation: Select One  Democrat  Republican  Independent 

What county do you reside? (If Baltimore City, just write city)

Which of the following best describes your total household income for last year before taxes? Select One  Under $15,000  $15,000 - $19,999  $20,000 - $24,999  $25,000 - $29,999  $30,000 - $39,999  $40,000- $49,999  $50,000 - $74,999  $75,000 - $99,999  $100,000 - $149,999  $150,000 and over 

Do you have internet access at: Home  Work  Spouse's Work   Do not have Internet access 

How did you hear about us? Select One  Family/Friend  Ad in paper  Word of Mouth  From a person who is already on our database