Complete this initial intake form for a team member to contact you and further investigate the mercury exposure you may have endured. Name * First Name Last Name Did you or a family member work at the Olin Corporation plant in Charleston, Tennessee? * Myself Family Member Were you or your family member a contractor or employee at work at the Olin Corporation plant in Charleston, Tennessee? * Contractor Employee Family Member was a Contractor Family Member was an Employee If you were a contractor, what company did you work for? Please include any additional details or information you may think is important for us to know about your symptoms and exposure. Phone * (###) ### #### Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Thank you for completing this initial form. A team member will be in contact with you to further investigate the mercury exposure you may have endured.
