First Responder Sign-up

First Responders, Thank you for all you do!!

Please complete the information below for your complimentary sample unit of Genie’s Hemp Signature Blend

First Responder's Information

Name *

First

Last

Email *

Address (Needed to ship your complimentary unit of Hemp Signature Blend) *

Address Line 1

City

State / Province / RegionAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone *

• Check this box to opt into SMS messages from Genie's about exclusive First Responder Discounts. (Standard Message Rates Apply)

Line of Work *

• Armed Services
• Police
• Fire
• EMS
• Hospital Staff
• Search and Rescue
• Detection
• Other

Upload a picture/PDF of ID card

Click or drag a file to this area to upload.

Your Best Friend's Information

Name of your Furry Friend *

Breed

Weight *

Birthday

DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Upload a picture of your furry best friend

Click or drag a file to this area to upload.

Checkboxes

• By checking this you give Genie's Therapeutics permission to use your picture on social media

How did you find out about our First Responder's Program? *

Submit