Round-Up Pre-Qualification Form

First name

Last name

Email

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Birthday

Month

Day

Year

Have you or a loved one been regularly exposed to the brand Roundup weed killer?

Yes

No

How were you exposed to Roundup?

Personal/Home Use

Farming

Landscaping/Occupational

How long were you exposed to Roundup?

3-5 years

5+ years

What type of cancer were you diagnosed with? (select all that apply)

Are you currently represented by an attorney for this matter, or have you previously worked with an attorney regarding this claim?

Yes

No

I confirm that all information provided is truthful and accurate. I understand that my claim will require verification through medical records, cancer diagnosis documentation, identification, proof of Roundup exposure, and any other supporting documentation. Providing false information will result in immediate disqualification.

I consent to being contacted by Poca Lead Logic by phone, email, or text regarding my potential case.

You Did the Work and Your Health Paid the Price.