APPLICATION FOR CRYOPRESERVATION

     CRYOCARE FOUNDATION
     1013 Centre Road
     Suite 301
     Wilmington, Delaware 19805-1297

<<< When signing up with CryoCare, please use the hardcopy paperwork >>>
<<< provided by CryoCare rather than your own printout of this file. >>>

     I. Personal

     1.  Full Name   _______________________________________________
     2.  Address     _______________________________________________
                     _______________________________________________
     3.  Telephone(s)   ____________________________________________

     4.  Date of Birth  __________________________
     5.  Social Security Number ____________________

     6.  Occupation ________________________________________________
     7.  Employer   ________________________________________________
         Address    _______________________________________________ 
                    ________________________________________________
         Telephone(s)   ____________________________________________


     II.  Next of Kin

     A.   Spouse

     1.  Spouse's Name  ________________________________________
     2.  Address        ________________________________________
         (if different) ________________________________________
     3.  Telephone(s)   ________________________________________
     4.  Date of Birth  ______________________

     5.  Signed Relative's Affidavit?  Yes ______  No ______

     6.  Comments     __________________________________________


     B.  Children.
     List all living children, whether biological, adopted, or step
(indicate which).  Add sheets as needed.

     1. 
     a.  Name     __________________________________________
     b.  Address  __________________________________________
                  __________________________________________
     c.  Telephone(s) ______________________________________
     d.  Date of Birth _____________________

     e.  Signed Relative's Affidavit?  Yes ______  No ______

     f.  Comments ____________________________________________
         _____________________________________________________
             
     2.
     a.  Name       __________________________________________
     b.  Address    __________________________________________
                    __________________________________________
     c.  Telephone(s) ______________________________________
     d.  Date of Birth _____________________

     e.  Signed Relative's Affidavit?  Yes ______  No ______
     f.  Comments ________________________________________
         ______________________________________________

     3.
     a.  Name __________________________________________
     b.  Address _________________________________________
                 _____________________________________________
     c.  Telephone(s) ______________________________________
     d.  Date of Birth _____________________

     e.  Signed Relative's Affidavit?  Yes ______  No ______

     f.  Comments ________________________________________
         ______________________________________________

     _____ Check here if adding children's names on extra sheets.

     C. Parents, brothers, and sisters.
     Include biological, adoptive, and step
     (indicate specifically which).  Add more sheets as necessary.

     1. 
     a.  Name __________________________________________
     b.  Address _________________________________________

     c.  Telephone(s) ______________________________________
     d.  Date of Birth _____________________

     e.  Signed Relative's Affidavit?  Yes ______  No ______

     f.  Comments ________________________________________


     2.
     a.  Name __________________________________________
     b.  Address _________________________________________

     c.  Telephone(s) ______________________________________
     d.  Date of Birth _____________________

     e.  Signed Relative's Affidavit?  Yes ______  No ______

     f.  Comments ________________________________________
                  ______________________________________________

     3.
     a.  Name __________________________________________
     b.  Address _________________________________________

     c.  Telephone(s) ______________________________________
     d.  Date of Birth _____________________

     e.  Signed Relative's Affidavit?  Yes ______  No ______

     f.  Comments ________________________________________

     _____ Check here if adding parents' or siblings' names on extra sheets.

     D.
     If you have listed less than three (3) names so far, consult your
attorney concerning your remaining next of kin to see if anyone else could
have claim to your estate.  If so, they should be listed on a separate sheet
of paper  in the same format as above, and they should each sign a Relative's
Affidavit.  Be sure to indicate whether or not each relative has actually
signed the Relative's Affidavit.

     _____ Check here if adding names on a separate sheet.


     III. Health and Emergency Information

     1.  Personal physician or Health Maintenance Organization (HMO).

     Name ________________________________________________
     Address _______________________________________________
             ___________________________________________________
     Telephone: Office _______________   Home _______________

     Hospital _______________________________________________
     Address _______________________________________________              
                                                              
     Has Physician or HMO Director signed Physician's Affidavit?

     Yes ______  No ______

     To what extent will this person or organization cooperate with Cryocare?

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________


     2.  Medical Information

     Sex ______     Height ______     Weight ______    Blood Type ______

     Health Problems (Use extra sheets if necessary.  Please be specific.)

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     Health Problems (continued) __________________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     _____ Check here if continuing on extra sheets.


     Allergies (including to drugs) __________________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     Medications currently or recently taken ____________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________


     Past medical history (including major illnesses,
operations, hospitalizations, injuries or other problems. 
Use extra sheets if necessary.)

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     _____ Check here if your medical history is continued on extra sheets.


     Are there any hereditary illnesses or tendencies in your family?

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________


     IV.  Legal Information

     1.  Attorney ______________________________________________
     Address _______________________________________________
    
     Telephone:  Office ________________  Home ________________

     Signed Attorney's Affidavit?  Yes ______  No ______

     To what extent will your attorney cooperate with Cryocare?

     ___________________________________________________

     ___________________________________________________

     2.  Executor of your estate ______________________________________
     Address _______________________________________________
    
     Telephone:  Office ________________  Home ________________

     Signed Executor's Affidavit?  Yes ______  No ______

     To what extent will your executor cooperate with Cryocare?

     ___________________________________________________

     ___________________________________________________

     3.  Have you executed a will?  Yes ______  No ______

     Is your desire to be cryopreserved detailed in your will?

     Yes ______  No ______

     Have you included two (2) copies of your will with this application?

     Yes ______  No ______

     Comments _____________________________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________


     V.
     Other Persons Or Organizations We May Or Should Contact In Case Of
Emergency? (Include other sheets if necessary).

     1.
     a.  Name ___________________________________________
     b.  Address __________________________________________
                 ______________________________________________
     c.  Telephone(s) _______________________________________
     d.  Purpose for contacting _________________________________
         _______________________________________________


     2.
     a.  Name ___________________________________________
     b.  Address __________________________________________
                 ______________________________________________
     c.  Telephone(s) _______________________________________
     d.  Purpose for contacting _________________________________
         _______________________________________________
    
     3.
     a.  Name ___________________________________________

     b.  Address __________________________________________
                 ______________________________________________
     c.  Telephone(s) _______________________________________
     d.  Purpose for contacting _________________________________
         _______________________________________________
    
     4.
     a.  Name ___________________________________________
     b.  Address __________________________________________
                 ______________________________________________
     c.  Telephone(s) _______________________________________
     d.  Purpose for contacting _________________________________
         _______________________________________________

     _____ Check here if you have additional names.

     VI. Method Of Providing Suspension Funds

     I have chosen and arranged for the following method(s) to provide funds for the
cryopreservation and storage of my human remains:

     A.  ______ Life Insurance (enclose copy of policy and related documents,
including a schedule of beneficiaries and the method you have chosen to assure
that Cryocare will be notified if your policy is cancelled.)

     Company Name __________________________________________
     Policy Number ____________________  Date Issued ______________

     Policy Type ____________________________________________
     Policy Amount ______________________

     Address of Company _______________________________________
                        ________________________________________
     Telephone _____________________________________________

     Your agent's name ________________________________________
     Address ______________________________________________
             __________________________________________________
     Telephone ____________________________________________


     B.    ______ Private Trust Fund (enclose copy of appropriate documents,
including guarantee that Cryocare will be notified if Trust is cancelled or
reduced.)

     Institution ____________________________________________
     Address ______________________________________________
             __________________________________________________
     Telephone ____________________________________________
     Administrator ___________________________________________
     Account Number _________________________________________
     Amount in account ________________________________________
     Amount anticipated before death ________________________________

     C.    ______ Other instrument for conveying funds.  (Describe below and
include copies of appropriate documents.)
         
     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________

     ___________________________________________________



     Signature of Patient __________________________________________

     Date _________________