• Do You Qualify?

  77% of American 18-24 do not Qualify, Do You?
• Name*
  First NameLast Name
• Phone Number*
  Please enter a valid phone number.
• What is Your Date Of Birth?*
  Please select a month January February March April May June July August September October November December Month Please select a day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day Please select a year 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 Year
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• Gender*
  MaleFemale

• Citizenship

• *
  U.S. CitizenGreen Card HolderOther
• Place of Birth (city & state)*
• Back

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• Highest Education completed.*
  Still in High SchoolDropped out before 10th gradeDropped out before 11th gradeDropped out during 12th gradeCompleted High SchoolCurrently in CollegeCompleted College

• Educational Status

• What (High School / College) Did You Last Attended?*
• What Year (Did / Will) Graduate?*
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• Physical Stature

• How Tall Are You?*
• What is Your Current Weight?*
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• Medical Screening

• Have You Ever Broken Any Bones*
  NoYes
• What Have you broken?
• Implanted Hardware? (Pins/Plates/Screws)*
  YesNo
• Location?
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• Medical Screening - con't

• Do You Have Vision Trouble?*
  Contacts / GlassesLazy EyeAstigmatismColor BlindnessNoneOther
• Have You Ever Had Any Operations or Surgeries*
  Tonsils RemovedWisdom Teeth RemovedAdenoids RemovedAppendix RemovedNoneOther
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• Medical Screening - con't

• Have You Been To or Treated By Any Medical Professionals*
  Emergency RoomPsychologistHospitalUrgent CareNoneOther
• Have You Ever Been Prescribed Medication?*
  YesNo
• What Type of Medication?
• When were they filled by a pharmacist?
   -Month -DayYear

  Date
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• Medical Screening - con't

• Do Currently Have Asthma / Breathing Trouble?*
  YesNo
• Do You Have LIFE THREATENING Allergies?*
  YesNo
• What Are You Allergic to?
• Ever Been Diagnosed With Any Medical Conditions?*
  YesNo
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• Tattoo's

• Do You Have any Tattoos?*
  YesNo
• Location of Tatoos:
  Head / Neck / FaceWrist / hand / FingersArms/ Chest / BackLegs / FeetOther
• Content of Tattoos?
  DrugsSex / NudityOffensive languageGang / Criminal RelatedNone of the Above
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• Dependents Status

• Do You Have Any Kids / Dependents*
  NoneChildrenSpouseOther
• Have You Had Any Legal Troubles of Any Kind*
  YesNo

• Legal Trouble

• *
  ArrestedFingerprintedTicketedOther
• If Any, What Were The Legal Troubles.
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• Should be Empty: