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Birth Date:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Gender:
Male
Female
Have you used tobacco in the last 12 months?
Yes
No
Cigarette
Never
last 12 months
More than 1 yr
More than 2 yrs
More than 3 yrs
More than 4 yrs
More than 5 yrs
More than 6 yrs
More than 10 yrs
More than 15 yrs
More than 25 yrs
Cigar
Never
last 12 months
More than 1 yr
More than 2 yrs
More than 3 yrs
More than 4 yrs
More than 5 yrs
More than 6 yrs
More than 10 yrs
More than 15 yrs
More than 25 yrs
Pipe
Never
last 12 months
More than 1 yr
More than 2 yrs
More than 3 yrs
More than 4 yrs
More than 5 yrs
More than 6 yrs
More than 10 yrs
More than 15 yrs
More than 25 yrs
Snuff
Never
last 12 months
More than 1 yr
More than 2 yrs
More than 3 yrs
More than 4 yrs
More than 5 yrs
More than 6 yrs
More than 10 yrs
More than 15 yrs
More than 25 yrs
Cigarello
Never
last 12 months
More than 1 yr
More than 2 yrs
More than 3 yrs
More than 4 yrs
More than 5 yrs
More than 6 yrs
More than 10 yrs
More than 15 yrs
More than 25 yrs
Chew
Never
last 12 months
More than 1 yr
More than 2 yrs
More than 3 yrs
More than 4 yrs
More than 5 yrs
More than 6 yrs
More than 10 yrs
More than 15 yrs
More than 25 yrs
Marijuana
Never
last 12 months
More than 1 yr
More than 2 yrs
More than 3 yrs
More than 4 yrs
More than 5 yrs
More than 6 yrs
More than 10 yrs
More than 15 yrs
More than 25 yrs
Prescribed
Never
last 12 months
More than 1 yr
More than 2 yrs
More than 3 yrs
More than 4 yrs
More than 5 yrs
More than 6 yrs
More than 10 yrs
More than 15 yrs
More than 25 yrs
Province:
Amount:
Face Amount
$ 25,000
$ 30,000
$ 35,000
$ 40,000
$ 45,000
$ 50,000
$ 55,000
$ 60,000
$ 65,000
$ 70,000
$ 75,000
$ 80,000
$ 85,000
$ 90,000
$ 95,000
$ 100,000
$ 125,000
$ 150,000
$ 175,000
$ 200,000
$ 225,000
$ 250,000
$ 275,000
$ 300,000
$ 325,000
$ 350,000
$ 375,000
$ 400,000
$ 425,000
$ 450,000
$ 475,000
$ 500,000
$ 550,000
$ 600,000
$ 650,000
$ 700,000
$ 750,000
$ 800,000
$ 850,000
$ 900,000
$ 950,000
$1,000,000
$1,250,000
$1,500,000
$1,750,000
$2,000,000
$2,250,000
$2,500,000
$2,750,000
$3,000,000
$3,500,000
$4,000,000
$4,500,000
$5,000,000
$6,000,000
$7,000,000
$8,000,000
$9,000,000
$10,000,000
$11,000,000
$12,000,000
$13,000,000
$14,000,000
$15,000,000
$16,000,000
$17,000,000
$18,000,000
$19,000,000
$20,000,000
$21,000,000
$22,000,000
$23,000,000
$24,000,000
$25,000,000
$26,000,000
$27,000,000
$28,000,000
$29,000,000
$30,000,000
Type:
