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First Name: *
Last Name: *
Address: *
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Postal Code: *
Home Phone Number:
E-mail Address: *
SMS/Text Message Enabled Phone:
Language Preference: *		English French
Gender: *		Male Female
When were you born? *		Day (DD) /Month (MM) /Year (YYYY)
What brand of beer do you drinkmost often? * (Be honest!)		Select one Alpine Alpine Light Alpine Summit Alpine Max Clancy Moosehead Dry Ice Moosehead Lager Moosehead Light Moose Light Lime Moosehead Pale Ale Moosehead Premium Dry Becks Big Rock Brick Bud Light Budweiser Cracked Canoe Carlsberg Cold Filtered Light Coors Light Corona Creemore Guinness Heineken James Ready 5.5 James Ready Original Ale James Ready Light Keith's Kokanee Labatt Blue Labatt Light Lakeport Lucky Lager Miller Genuine Draft Molson Canadian Rickard's Red Sleeman Stella Artois Other
Name two other brands that you drink occasionally:		Select one Alpine Alpine Light Alpine Summit Alpine Max Clancy Moosehead Dry Ice Moosehead Lager Moosehead Light Moose Light Lime Moosehead Pale Ale Moosehead Premium Dry Becks Big Rock Brick Bud Light Budweiser Cracked Canoe Carlsberg Cold Filtered Light Coors Light Corona Creemore Guinness Heineken James Ready 5.5 James Ready Original Ale James Ready Light Keith's Kokanee Labatt Blue Labatt Light Lakeport Lucky Lager Miller Genuine Draft Molson Canadian Rickard's Red Sleeman Stella Artois Other Select one Alpine Alpine Light Alpine Summit Alpine Max Clancy Moosehead Dry Ice Moosehead Lager Moosehead Light Moose Light Lime Moosehead Pale Ale Moosehead Premium Dry Becks Big Rock Brick Bud Light Budweiser Cracked Canoe Carlsberg Cold Filtered Light Coors Light Corona Creemore Guinness Heineken James Ready 5.5 James Ready Original Ale James Ready Light Keith's Kokanee Labatt Blue Labatt Light Lakeport Lucky Lager Miller Genuine Draft Molson Canadian Rickard's Red Sleeman Stella Artois Other
Please tell us what other alcoholic beverage(s) you drink?		Wine: glasses/week Liquor: glasses/week Coolers: glasses/week
How many beers do you usually drink in a week?		Select one 0 1-6 7-12 13-24 25+
Of the last 36 beers you have drank at home, approximately how many were the beer you drink most often?		Select one 0-6 7-12 13-18 19-24 25-30 31-36
Check your top 3 favourite activities:		Listening to music: Pop/Rock Jazz/Blues Country Urban/Hip-hop Participating in or Watching: Hockey Baseball Snowboarding/Skiing Golfing Hunting Fishing Snowmobiling Curling Soccer Auto Racing Football Video Games Fitness Basketball Home Improvements	Reading: Books Magazines Newspaper
Please enter the Moosehead Lager UPC code from the top of your beer case or on the side of your can. ex. 7 7600000133 3	*
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Moosehead's Privacy Statement The information you share with us helps us to understand your needs and preferences. That way, we can serve you even better in the future. We appreciate your privacy and guarantee that what you tell us remains between us. We'll make sure that the information you give us is confidential and will only be used with your permission by Moosehead Breweries Limited.

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