Name (first & last)* Age* Month January February March April May June July August September October November December Day 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 28 29 30 31 Address* City * State * Zipcode* E-mail* Comments Add me to the Fan Club Add me to the Mailing List Add me to the KULT!
Areas marked with * must be filled out in order to join the mailing group and the Fan Club. No personal information such as address, city, or zipcode will be placed on the KULT list. MKULTRA insures that no personal information will be distributed in any way.