Patria Soli | Receiver Form

Your Name:

Your Email Address:

Your Mailing Address:

Location where you want to have soil from:

Are you requesting soil from somebody you know?

Yes

If you answered "Yes" above, please provide us the person's name, email address, and mailing address.

Are you also interested in our help with the end of life conversations with somebody?

Yes (Please provide us how we can help you in the commnet section at the end)

Would it be ok with you if your name (first name only) and location appear in our photographs, website, and artwork?

I agree with Patria Soli to use my first name and location in their documentations and artworks.

Please do not use my name and location in any documatations. (Please understand that your name and location appear on the soil bottle)

If you have any other comments, please use here.

Thanks for perticipaton!