We want to learn about you!

We want to get to know our audience a little better!

The following forms lets us know who you and the rest of our audience is! It lets us know who is watching. It is short and simple, and upon completion of the form you will automatically be sent a copy of Rose Lee Archer's How To Be a Media Magnet!

It is extremely important that you answer all information as accurately as possible! This will best ensure and expedite review process of your story!

*AGAIN THIS INFORMATION IS SOLELY USED TO ALLOW US TO KNOW WHO OUR AUDIENCE IS AND IN ABSOLUTELY NOW WAY WILL BE USED TO DETERMINE SELECTION FOR THE TELL US YOUR STORY CONTEST!*

Please answer to the best of your ability

UPON COMPLETING THE SURVEY ACCURATELY YOU WILL BE AUTOMATICALLY SENT A COPY OF THE BOOK “HOW TO BE A MEDIA MAGNET”

Any Question Marked with an asterisk * Must be filled in and completed correctly!

First Name*		Street Address*			City* State*ll
Last Name*		Gender*		Marital Status*			Zip Code*ll

Rose Lee Archer is a Disability Advocate. The following information helps Rose Lee better understand her audience.

How long have you been watching the show for?

How did you hear about the show:

How many persons in your household are ages of 0 and 21?*		Any persons with disability?
How many persons in your household are ages of 22 and 55?*		Any persons with disability?
How Many persons in your household are ages of 56 and over?*		Any persons with disability?

Please Select any issues you have seen on the show

(Hold the Shift Key to select multiple options. Highlight as many as you have seen.)

Briefly describe how you feel about the show:

You have successfully completed the survey. Once you hit submit we will receive your query and a copy of How to Be a Media Magnet Book will be sent right to you. Please allow 4-5 Business Days. After clicking submit you will continue on to the next step which will be telling us your story for an opportunity to get on the Rose Lee Archer Show and share your issue!

Please Click Submit to Continue

To start again by resetting the form click below