1. FIRST name
 
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2. LAST name
 
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3. Street Address (and apartment number)
 
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4. City
 
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5. State
 
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6. Zip Code / Postal Code
 
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7. Country of Residence
 
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If "Other", please provide the name of the country.
8. Mobile Number
 
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9. What is your date of birth?
 
   
10. Height
 
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11. Weight
 
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12. Please select the best answer related to smoking and tobacco use (including any form of nicotine products, including e-cigarettes, Hookah, Nicotine patch, chewing tobacco)
 
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Please explain for how long you smoked or used tobacco, at what age, how long ago did you quit
13. Have you traveled to a Zika infested area or been infected with Zika Virus within the past 12 months?
 
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If Yes, Please Explain:
14. Is there anything in your history, the history of someone with whom you have been intimate, or with whom you live with, related to:
 










It is very important that you explain in detail anything referenced above.
15. Do you have hemophilia or other related clotting disorders and have received human-derived clotting factor concentrates in the preceding five years, not including receiving clotting factors once to treat an acute bleeding event more than 12 months ago?
 
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16. Is there anything in your history or the history of someone with whom you have been intimate, who has ever:
 












It is very important to explain in detail any item referenced above.
17. Which of the following have you had?
 










It is very important that you explain in detail anything referenced above.
18. Have you ever injected drugs or had a sexual partner who did so?
 
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Why type of drug was injected? Why was this drug used?
19. What is your email address for communication with you regarding your pre-screen application?
   
20. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
21. Verify your password.
   

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