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Gasoline Assistance Application


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Gasoline Assistance Application

Please read this application agreement thoroughly before signing.

First Name: ____________      Middle Initial: ___      Last Name: _______________ 

Address: _____________________________________________________________

City: ______________________      State: ____      Zip Code: __________________

Please check all that apply to you: 

___ Have no other means of transportation other than a vehicle that operates on gasoline. 

___ Believe that hitch hiking is a dangerous form of transportation. 

___ Physically unable to stowaway in the trunk of a neighbor's car for a free ride to town. 

___  Have depleted all financial resources including but not limited to savings, 401k,  inheritance, etc. 

___ Everyone in your neighborhood has locking gas caps on their vehicles. 

___ Been denied citizenship to Venezuela where rumor has it that gas prices are around $0.14 per gallon. 

In order to qualify for gasoline assistance you must agree to and abide by the terms listed below. You are agreeing to participate in practices that could be deemed unethical, studies, of which could have devastating consequences. Upon signing this document you will be waiving your rights to legal counsel and compensation for any adverse side effects, encounters, etc. you may experience.

For receiving compensation towards your gasoline budget you agree to be a test subject in future trials pertaining to questionable experimentations that will require your complete cooperation.

Compensation amounts: $0.0000001 per gallon will be paid out only after proof of experimentation has taken place. Payments will be mailed out 36,523 days after last day of experiment and will be made payable to the actual participant. 

I have read all the guidelines and agree to abide by all the terms listed above. 

Date: ________________________________ 

Print Name: ___________________________ 

Signature: ____________________________ 

Mail To: 

Quantum Field Study Team 

Cosmic Substation 9, Mars Q10R92 

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