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Square1: The LiiFE Experience Survey

Thank you for signing up with the Pinky Cole Foundations Square 1: The Life Experience buy a black man an insurance plan. We want to make sure we have all your information verified as the next steps is for the insurance company to contact you and certify you qualify for the free insurance program. Please click the link and fill out ALL information electronically.

Name*
Address*
MM slash DD slash YYYY
Sex:*

Are you between the ages of 18-45?*
Do you smoke cigarettes?*
Do you earn $30,000 a year or less?*
Are you a Slutty Vegan or Bar Vegan Employee?*
Would you like to see more information on Square1: The Liife Experience?*
What are you interested in?*