HOST NAME: ___________________________________

HOST MAILING ADDRESS: ______________________

______________________

HOST SOCIAL SECURITY NUMBER (for honorarium check):

______________________

E-MAIL ADDRESS FOR CONTACTING HOST ABOUT
SURVEYS, IF NEEDED: ______________________

MEETUP DATE: ______________________

MEETUP VENUE (CITY & STATE):

______________________

NUMBER OF SURVEYS RETURNED: _____________

May we identify you as the Meetup Venue Host in our reports?

YES [ ] NO [ ]