Rudi Hoffman - CERTIFIED FINANCIAL PLANNER™

Cryonics Form

Information Request Form

Select the items that apply, and then let us know how to contact you.

Name
Address
E-mail
Phone
Tobacco Usage	Yes No
If Yes, when did you quit?
Sex	Male Female
Marital Status	Married Single
Birth Date
Preferred Cryonics Vendor	Alcor Cryonics Institute American Cryonics Society Unsure
Form of Suspension	Full BodyNeurosuspension Unsure
Height
Weight
Occupation
Hazardous Sports
Pre-existing Health Issues
Did either of your parents have heart problems or cancer before age 60?	Yes No
If Yes, which?	Heart Cancer Both
In the past 3 years, have you traveled outside the US?	Yes No
In the last 5 years, have you had any moving violations?	Yes No
If Yes, which?	Speeding DUI Other

Telephone (386) 788-3773 • Toll Free 1-800-749-3773 • FAX (386) 322-1979
PO Box 290549, Port Orange, FL 32129
General Information: rudihoffman@aol.com

Offering securities through Broker Dealer Financial Services Corp., member NASD/SIPC 800-352-5634.

It is understood that information provided on this site is confidential and will be maintained in a confidential and professional manner. It is understood this information is provided strictly for the purpose of obtaining a realistic and competitive life insurance or investment quotation, and this information will be kept confidential.

Certified Financial Planner Board of Standards, Inc. owns the certification marks CFP®, CERTIFIED FINANCIAL PLANNER™ and federally registered CFP (with flame logo) in the U.S., which it awards to individuals who successfully complete CFP Board's initial and ongoing certification requirements.