Date of birth:
E mail address:
City and state in which you
Name and e mail address of
individual to serve as a contact person:
suffer from a terminal illness?
If yes please explain.
know of the time reference concerning
your death? If yes please explain.
currently reside in a
correctional facility? If yes please explain.
participate in recreational use
of illegal substances?
ever considered suicidal
thoughts or attempted to take your own life?
ever been or are you currently
under psychiatric care? If yes please explain.
Please explain your interest in
participating in this program.
This program is designed for
entertainment purposes only and is not affiliated with nor does
it endorse any political, religious or ethical beliefs or
organizations. Only applicants may complete this form and must
be of sound mind. Participation in the program is on a voluntary
basis. Applied Technologies, LLC takes no responsibility for any
actions carried out by the applicant or anyone associated with such
Do you understand and
agree to the terms stated above?
Do you want you participation in
this program documented publicly?