Cryonics Advice & Services | Cryonics4U

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Cryonics Advice & Services | Cryonics4U

Home
Application
Investors
FAQ’s
Forum
Empirical Data
Media
Contact

Home
Application
Investors
FAQ’s
Forum
Empirical Data
Media
Contact

Application

Application

Please complete the form below and we’ll contact you to arrange a no fee consultation.

Full Name*
First Last
Address*
Street Address City County / State / Region ZIP / Postal Code Country
Age
Height
Weight
Date of Birth
Date Format: MM slash DD slash YYYY
Nationality
Religion
Profession
Industry
Annual Income
Mobile Number*
Home Telephone
Email Address*
Any Cryonics memberships?
- YES
- NO
Suffering from any form of illness or depression? Please tell us more
- YES
- NO
Please provide more details
Any bad habits or addiction? Please tell us more.
- YES
- NO
Please provide more details
Criminal convictions?
- YES
- NO
Interested in Cryonics Insurance?
- YES
- NO
Already decided about being Cryopreserved?
- YES
- NO
Interested in individual or group consultation?
- Individual
- Group
Please complete details below for group, partner or family member
Full Name
First Last
Contact number
Email address
Home address
Street Address City County / State / Region ZIP / Postal Code Country
Add another person?
- YES
- NO
Full Name
First Last
Contact number
Email address
Home address
Street Address City County / State / Region ZIP / Postal Code Country

Contact Info

700/100 Regent Srinakarin TowerPrachit Alley, Suan LuangBangkok, Thailand, 10250

+66 2 040 7884

mail@cryonics4u.com

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