| First Name | : | * |
| Last Name | : | * |
| Home Phone Number | : | * |
| Office Phone Number | : | |
| Cell Phone Number | : | |
| Address | : | * |
| City | : | * |
| State | : | * |
| Zip Code | : | * |
| Email | : | * |
All contestants must be at least 8 years of age! | : | |
| Choose Your Gender | : | |
| Which Edition of Coffee News? | : | |
| What is the cover date? | : | |
| Which ad is Little Bill in? | : | |
Where did you Pick Up or Read Coffee News? | : | |
| Comments? | : | |
| | * denotes required fields |