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| 1. |
Please enter your contact information
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| 2. |
Country or Region of the World
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| 6. |
What is your race or ethnic background? The answer to this question may be important in determining target selection.
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| 7. |
What is your religious affiliation?
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| 8. |
Highest Education Level
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| 10. |
If yes, what type of job do you have?
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| 11. |
Do you have a website?
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| 12. |
If so, what's the url? Or leave blank.
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| 14. |
If so, what's the url? Or leave blank.
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| 15. |
Where did your targeting start?
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| 16. |
When did your targeting start?
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| 17. |
If outside the US, in what country or region did your targeting begin?
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| 18. |
Who do you believe is targeting you? You may select one or more responses
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| 19. |
Are you an organized stalking victim?
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| 20. |
Are you a Directed Energy Weapons victim?
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| 21. |
Has your physician been of any support or assistance to you in treating your medical condition(s) due to the directed energy assaults?
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| 22. |
Have you reported your harassment to your local police?
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| 23. |
If yes, what was their response? You may select one or more responses.
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| 24. |
Have you reported your harassment to the FBI?
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| 25. |
If yes, what was their response? You may select one or more responses.
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| 26. |
Have you sought assistance regarding your harassment from your state or congressional officials?
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| 27. |
If yes, what was their response? You may select one or more responses.
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| 28. |
When your targeting began, did you live near a military base?
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| 29. |
When your targeting began, did you live near a defense contractor(s)?
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| 30. |
When your targeting began, did you live near a weapons manufacturer(s)?
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| 31. |
When your targeting began, did you live near a US intelligence agency?
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| 32. |
When your targeting began, did you live near a major university(ies)?
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| 33. |
When your targeting began, did you live near a major hospital?
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| 34. |
When your targeting began, did you live near a biomedical research facility?
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| 35. |
When your targeting began, did you live near a public or private psychiatric facility?
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| 36. |
Organized Stalking Activities. Please check all that apply.
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| 37. |
Directed Energy Weapons Assaults. Please check all that apply.
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