Havana Syndrome Survey
Welcome to Our Survey
Please take a minute to complete all questions as your opinion matters to us.
We utilize your feedback to improve our products and services.
Thank you,
Management.
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1.
First and last name?
2.
City of residence?
3.
State of residence?
4.
Country of residence?
5.
Phone number?
6.
Email address?
7.
Preferred method of contact?
Please Select
Phone
Email
8.
What part of the state do you live that in?
Please Select
Northeast
Northwest
Southeast
Southwest
Central
9.
Which region do you live?
Please Select
Africa
Asia
Australia
Europe
Middle East
North America
South America
10.
What is your gender?
Please Select
Male
Female
Other
Decline to answer
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