QC VIP Registration Form
VIP Registration Form
First Name
*
Last Name
*
Address
*
Cell Phone
*
Email Address
*
Gender
*
Please select...
Male
Female
Age Range
Please select...
16 - 20 yrs
21 - 30 yrs
31 - 40 yrs
41 - 50 yrs
51 - 60 yrs
61 - 70 yrs
70+ yrs
Please enter your unique VIP card number.(number is found on the back of card)
*
Please enter the Date of purchase:
*
Where did you purchase your VIP card?
*
How would you like us to keep you in the loop? (Check ALL that apply)
*
I would like to receive the Free weekly VIP E-Newsletter
I would like to receive Free Text Alerts (max 10 per month)
I would like the Free MyNightOut Droid App on my smart phone
I don't want to be kept in the loop
Take a minute and help us make your VIP experience even better!
What made you choose to become a VIP member?
How often do you go out weekly?
Please select...
Couple times a month
1-2 nights per week
3-4 nights per week
5-6 nights per week
Every night
What is your average household income?
Please select...
$10,000 - $20,000
$21,000 - $30,000
$31,000 - $40,000
$41,000 - $50,000
$51,000 - $60,000
$61,000 - $70,000
$71,000 - $80,000
$81,000 - $90,000
$91,000 - $100k
$100k +
What business or type of business would you like to see on the VIP card?
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