| 1. |
Did you qualify for programs? |
Yes
No
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| 2. |
On a scale of 1 to 5, how helpful was the program? |
5 Very helpful
4
3
2
1 Not helpful
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| 3. |
Please tell us about your experience: |
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| 4. |
Age range: |
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| 5. |
City: |
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| 6. |
State: |
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| 7. |
First Name: |
* Required |
| 8. |
Last Name: |
* Required |
| 9. |
Phone number (If you are willing to be contacted for more information about your experience): |
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| 10. |
Disclaimer: I hereby grant the Pharmaceutical Research and Manufacturers of America (PhRMA) an absolute, royalty-free, worldwide, perpetual, right and license to publish, reproduce, display, stream, broadcast, distribute, assign or license to anyone working for PhRMA, or use in any way whatsoever the written account identified above, in any media existing now or later created, for news, trade, advertising, art or any other lawful purpose. I hereby waive any right that I may have to inspect or approve the finished product or any written copy that may be used in connection herewith, or the use to which it may be put. I agree that PhRMA shall have the right to edit my written account without my consent. This Release and License Agreement shall be effective as of the date of this submission and shall apply to any and all subsequent use by PhRMA of the written account. |
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I have read this Release and License Agreement, understand it, and intend it to be a binding instrument. |
Yes
No
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