Title
Mr. Mrs. Ms. Miss Mr. & Mrs. Dr.

* First Name

* Last Name

* Email Address

* Phone Number

Cell Phone Number

Office Phone Number

Street Address

Apartment/Suite

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Zip Code

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Date of birth of person injured
(mm-dd-yyyy):

Do you know that Perchlorate is/was in your drinking water?
Yes
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If a government agency has tested your drinking water, please name the agency and describe the test results:

Date of water test:

Please describe the injuries suffered due to this toxic substance:

If other people in your neighborhood have experienced related illnesses, please describe:

What do you think was responsible for Perchlorate contamination (for example army base or military manufacturers plant):

Other Info:

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