*First Name
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| *What is your gender? |
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| *What is your age? |
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*Educational Level
(select the higest achieved): |
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*Contact Email Address
(Will not be disclosed, for use only in communicating about Chocolate Television or the Indie Food Channel) |
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| In your opinion, is this type of televison program needed for chocolate lovers? |
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| Do you currently watch food, wine and lifestyle television programs, and if so, how often? |
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| If you answered "Yes" to the previous question, please provide names of food, wine and lifestyle television program that you watch regularly (use commas to separate names) |
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| How many times a month do you eat outside the home? |
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| How many times a month do you cook at home? |
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| *What would you like to communicate to Chocolate Television? |
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Have you Ever Been on Television?
(Check box if "Yes") |
Yes
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I heard about this Television Program from
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Newspaper or General Magzine
PostCard
blog or website
Other Agent
Organization or Club
Friend
Craigslist
Search Engines
TCB-Cafe Publishing/Indie Food Channel
Television
Other
If 'Other,' please enter Reference Name or Promotional Code below
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