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First Name*

Last Name*

Phone*

e.g. 555-555-5555

Email*

Have you been exposed to PFOS/PFAS?*

Yes

No

How were you exposed to PFOS/PFAS?*

I was exposed to fire foam sprayed by a fire fighter/military personnel

I was exposed to contaminated drinking water while living on or near a military base

None of the Above

Have you been diagnosed with cancer?*

Yes

No

When would be a good time to call you?

Central Time

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I Consent