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QuantumMan: Financial Assistance
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QuantumMAN™ is completely aware of the hardships facing many people of different walks of life particularly in this current global economic recession. Because this technology was developed by a private humanitarian medical research group that "employs" QuantumMAN™, QuantumMAN™ offers financial assistance to those qualified so that no one is out of reach from this magnificent technology due to financial issues.

If you can not afford one of the following products, please complete QuantumMAN™'s FINANCIAL ASSISTANCE APPLICATION below and then submit for his consideration.

The products currently offered for financial assistance consideration are:

QFood™
Supercillin™

Check which product financial assistance is being applied for:

QFood™
Supercillin™

1. Name:
Last name first (e.g. Doe, John)

2. Sex: M F

3. Date of Birth:
Day/month/year

4. Address:


Street / apt #

City State


Country Zip code

5. Contact information:

Phone: Cell:

Fax: Email address:

6. Annual gross income: Less than $5,000 USD ; $5,000USD - $10,000USD ; $10,000USD - $25,000USD ; higher than $25,000USD .

7. Medical Insurance: yes No

8. Receiving welfare assistance: yes No

9. If #8 is answered yes, then specify type of assistance: .

Person completing this application form: self; family member
humanitarian organization

If family member: please print that person's full name:
and address if different from applicant:


Street Apt #


City State


Country Zip code

Family member's relationship to applicant: .

Name of humanitarian organization:

Address of humanitarian organization:


Street Bldg #

City State

Country Zip code

Name of representative of humanitarian organization:

Position:

Contact information of organization:
Phone #:

Cell #:

Fax #:

Email address:

11. If a humanitarian organization is requesting multiple protocols, please specify how many are desired: .
Please note that request for multiple protocols still requires a name, birth date, sex and address of each person the request is for before final authorization is granted.

Notice: All information is held as confidential.

All fields must be completed in order to submit.


Please input the above code
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Beware of imposters. Only Portal Access Keys™ (PAKs™) uploaded directly from this site (QuantumMANsite.com) are genuine and effective.

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