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Employing the mortality
handicapped since 1907

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Life Status

Do you have all your original body parts? Yes No
If you answered "No" above, please provide details:

Medical History
Do you suffer from any of the following common allergies or phobias? Click all that apply:	Pollen sensitivity Ragweed sensitivity Ultraviolet illumination immune deficiency Lunar Opalescence Aversion Religiously purified Dihydrogen Monoxide sensitivity. Silver Nitrate, Silver Oxide, Silver Chloride, or just plain "anything Silver" intolerance Faith based artifact phobias Pets Allergies.

Are you now or have you ever been dangerously radioactive? Yes No

Do you now or have you ever suffered from any of the following common addictions? Check all that apply:	Caffeinated coffee or other similar beverages Cigarettes, cigars, or other high nicotine products Red corpuscles or other similar beverages I eat brains

Other Information
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* Dihydrogen Monoxide.
That's two hydrogen
atoms combined
with one oxygen atom.
Sometime known as H20.
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For more information on Dihydrogen Monoxide and its harmful uses click here: