After Death Employment Application

(To be completed by applicant only)

You may copy this to your email program, answer the questions and send it to:




Date of birth:


Contact information:1

E mail address:

Phone number:

City and state in which you currently reside:


Name and e mail address of individual to serve as a contact person:


Do you: 

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?


Have you:

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 individual.

 Do you understand and agree to the terms stated above?

Do you want you participation in this program documented publicly?