1. Name:

2. Address:

3. City State Zip:

4. Have you driven an electric car previously:
Yes No

4. What time frame would you consider purchasing:
Now 1 Month 6 Months 1 Year or more

5. Have been in contact with any other Tesla employees, Sales Associates, or Tesla Owners in the past 14 days:
Yes No

6. If yes to #5, have they slept over at your house?
Yes No

7. Do you have any communicable diseases?
Yes No

8. Do you have any sexually transmitted infections?
Yes No