Let’s get you pre-qualified .Please answer the following questions. Name * First Name Last Name Gender: * Male, Female Date of Birth: * Phone * (###) ### #### Email * Pre Existing Medical Conditions * Examples: Cancer, High Blood Pressure, Under Medications, etc. Do you use tobacco or nicotine products? * Cigarettes, Vape, etc Location & Legal Status * Current Residential Address: Country of Citizenship: Are you a U.S. citizen or permanent resident? If no, what is your current status? Thank you!
