Please complete this application to determine if you qualify to be a Peer Mentor to sleep apnea patients.

Tell Us About You

First Name

Last Name

Email Address

Phone Number

Zip Code

Gender

Year of Birth

Time Zone

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Are you a shift worker, who usually works nights?

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Have you been using a PAP machine (CPAP, Auto PAP, Bilevel PAP) to treat your sleep apnea for at least one (1) year?

YesNo

Please tell us why.

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