For more information about participating in a study in your area, please complete the information below.

Social Security Number	ID Number
Last Name*	First Name*	Middle Name
Street Address*
City/Town*	State/Province	County
Zip Code/Postal Code*	Country
Phone #*	Occupation
Alternative Phone #	Alternative Phone Description
E-Mail Address*
Birth Date*	Age* Sex* -Select- Male Female	Race No Answer Native American Asian Black Caucasian European/Middle Eastern Hispanic
Availability for studies (check all that apply) Weekdays Weekends Short Visits Long Stays Summer Only Winters Only
Height*	Weight*	Frame Size S M L
Do you smoke?* Yes No
How much do you smoke on a daily basis? None 0-4 cigarrettes 5-9 cigarrettes 10-14 cigarrettes 15-19 cigarrettes 1 pack 1.5 packs 2 packs 3 packs 3+ packs Chew tobacco Cigar smoker Pipe smoker	Start Date
Do you use tobacco products of any kind? Yes No
Are you a former smoker? Yes No	How much did you smoke per day? None 0-4 cigarrettes 5-9 cigarrettes 10-14 cigarrettes 15-19 cigarrettes 1 pack 1.5 packs 2 packs 3 packs 3+ packs Chew tobacco Cigar smoker Pipe smoker
When did you start?	When did you quit?
In the space below, please list any medication(s) you currently take on a regular basis. Be sure to include the name of the medication, when you began taking it, and what you take it for.  If you are not taking any medication, please type "none".*
In the space below, please include any questions or comments you may have.

* Indicates required field