QUESTIONNAIRE FORM

Please fill out the following Questionnaire:

PLEASE FILL OUT YOUR  NAME:

QUALIFICATION:

ADDRESS:

STATE:    ZIP:     COUNTRY:

TELEPHONE:    FAX:

EMAIL:

ARE YOU A FARMER?                  YES                        NO

WHAT MEDICINAL PLANT YOU WOULD LIKE TO GROW?    

WHAT IS YOUR DEGREE?    

DO YOU HAVE ANY EXPERIENCE IN GROWING HERBS?

ARE YOU A PHYSICIAN OF ANY KIND? YES                   NO

IF YES, WHAT KIND?    

WHAT IS YOUR DEGREE?    

WOULD YOU LIKE TO JOIN OUR CLINICAL RESEARCH INSTITUTE?

YES                   NO