Please fill out all questions below.

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* 1. Please write your first name. 

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* 2. Please write your last name.

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* 3. Please provide your phone number

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* 4. Please enter your email address.

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* 5. What is your age?

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* 6. Select your sex at birth:

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* 7. What sex do you identify as now?

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* 8. What is your Sexual Orientation?

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* 9. What is your ethnicity? (Please select all that apply.)

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* 10. Would you like to pick up test kit or have it mailed?

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* 11. Please provide your mailing address ( ONLY FOR KITS MAILED TO HOME)

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* 12. Choose your nearest Health Department ( ONLY FOR PICK-UP):

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* 13. How did you hear about the HIV Self Test Kit Program?

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