Request Information - For Non-US Residents

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Please provide the following information to receive your free MHBP Benefits Information Package.



  (* Required information)


  *First name:  

  *Last name:  

  *Address:       

  *City:          

  *Region/Province:

  *Country:

  *Postal code:

  *Date of birth:

  *Are you a (check one):

     Federal employee or spouse
     Postal employee or spouse
     Federal or postal annuitant or spouse
  (Only members of these groups are eligible.)

  *If federal employee or spouse, please choose the agency or department you or your spouse works for:
  

   *Current health plan (check one):
  

  *Current coverage (check one):

   Self and family
   Self only

  Phone number:   - -

  E-mail address: 

  *How did you hear about this offer?

Newspaper
Magazine
Direct Mail
Internet
Health Fair
Email
Other

  Would you be willing to participate in future surveys, focus groups or website usability studies?
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No


  I give my permission for MHBP to send me information using the email I have provided
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No

    

 

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