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* 1. First Name

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* 2. Last Name

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* 3. Please enter your current residential address.

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* 4. In what county do you reside? (ex. Dauphin County, York County)

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* 5. Please enter the best telephone number(s) at which we can reach you for recruiting purposes.

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* 6. Does Lepson Research Group have permission to call or send you a text message (SMS) the express purposes of participation in research studies conducted by Lepson Research Group, Lepson Research Group's clients, and/or Lepson Research Group's research partners?

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* 7. Please enter an email address that you check on a regular basis at which we can reach you.

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