Agent Orange Survey


NOTE: All information supplied by you is confidential, and will be used only for the purpose of obtaining and presenting statistical data. You are asked to give us your name and address. We are requesting this information because there may be a need to contact you for additional follow-up questions. There may also be a need to verify the a ccuracy and validity of this survey, and this may require a need to contact you. Thank you for your time and patience in filling out this important survey.

INSTRUCTIONS: It is important that ALL questions are answered. If a question does not apply to you, please, either leave it at its default, or skip it. The choice of NA indicates Not Applicable. Kindly fill out the Personal Data form and check to ensure that the survey number is the same on both the Personal Data Form and the Survey itself.

Personel Data Form


VETERANS INFORMATION


Name? (required)
Title First M.I. Last
Suffix
Please provide your mailing address (required) 
     Street Address:      

     City:                

     State:               

     Zip:                 

County:      

Email Address: What is your electronic mail address?  (optional)
Type the survey number below into this box :
Survey Number #[TextCounter Fatal Error: Could Not Write to File _aosurpg4.shtml]
Please write down the number you see as your Survey number.
Please make sure this number is entered in the above space provided, and on the survey . This is most important.
Please click on the Submit button to submit this form or click the Clear button to erase the data from this form
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VIETNAM VETERANS OF FLORIDA, STATE COALITION
SELECT COMMITTEE ON AGENT ORANGE

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