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Initial Application

Please do not be discouraged if you have an unfavorable response to any of the questions below. Not all of the questions will indicate disqualifying factors.

    Full Name


    Phone Number


    Have you ever been a chronic user of nicotine products (including vapes)?

    Do you currently use any nicotine products (including vapes)?

    Have you ever been a chronic user of marijuana?

    When was the last time you used marijuana?

    Have you ever injected drugs or had a sexual partner who did so?

    Have you been seriously ill in the past 12 months?

    Your information is safe with us. We respect and protect your privacy. We will not rent, sell or share your personal information with outside companies for their promotional use. We will not distribute your personal information to outside parties without your consent.

    If you have any questions please contact us