Quality Reception Report

Quality Reception Report
Full Name *

First Name Last Name
E-mail
Address Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Occupation
Receiver Type
Antenna Type
Date *
UTC Time *
Frequency *
Program Name *
Comments on Program
Stength

Excellent Good Fair Poor Weak
Interference

None Slight Moderate Severe Extreme
Noise

None Slight Moderate Severe Extreme
Fading

None Slight Moderate Severe Extreme
Overall Merit

Excellent Good Fair Poor Unusable
Should be Empty: