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Media Survey Report

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How did you learn of our product? (1) Television Commercial(s)? Yes [ ] No [ ] If "Yes", which channel? (2) [ ] (7) [ ] (9) [ ] (10) [ ] When? Morning [ ] Afternoon [ ] Evening [ ] Late Night [ ] (2) Radio? Yes [ ] No [ ] If "Yes", which station? _______________.

When? Morning [ ] Afternoon [ ] Evening [ ] (3) Newspaper? Yes [ ] No [ ] If "Yes", which one? _________________ (4) Store Display? Yes [ ] No [ ] If "Yes", which store? ______________________. (5) Direct Mail? Yes [ ] No [ ] (6) Mail Order Ad? Yes [ ] No [ ] If "Yes", which publication? _______________. (7) Other __________________. (8) Additional comments: