First name
Last name
Address
City
State/Province/Locality
Country
Postal Code
Date Purchased
Month:
1
2
3
4
5
6
7
8
9
10
11
12
Day:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Model Number
Serial Number
Email Address
Dealer Purchased From
How was this product purchased?
In Store
Hamfest (Specify
)
Mail Order
Other (Specify
)
Why did you purchase this product?
Price
Design
Brand Name
Reputation
Features (Specify
)
Influences to purchase this product?
Recommendation from another ham
Advertising
Magazine Product Review
Salesperson
Other (Specify
)
Amateur Radio Magazines you read?
QST
Popular Communications
CQ
Monitoring Times
73
Worldradio
Spanish CQ
Other (Specify
)
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