Basic Application
Name _____________________________________________________
Address ___________________________________________________
City, State & Zip _____________________________________________
Date of Birth ________________________________________________
Height ____________		Weight___________     Sex ____________
Marital Status___________________
Do you smoke      Yes________	No _______________
Citizenship 	Yes __________	No ______________
Tell us about your health: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Are you on any medications? If so please list all with dosage information:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________					
Once you get back to us with this basic information we can do a search to locate the best company to fit your needs. We will email you the quote so you can see the numbers.  After that we will schedule a day and time to speak with you by phone to do your full application and schedule your paramed appointment to get your lab work done in the privacy of your home or work. 
Just email us this information to:  info@TaxFreeInformation.com.