Literal question
<svar a="all" v="US70A495 US70A423">[All]<br /><span class="h3">Date of birth </span><br /><br /><span class="em">5. Month and year of birth and age last birthday</span><br /><div class="i1">Print</div><br /><br /><div class="i2">Month</div><br /><div class="i3">_____</div><br /><div class="i2">Year</div><br /><div class="i3">_____</div><br /><div class="i2">Age</div><br /><div class="i3">_____</div><br /><br /><div class="i1">"If the month or year of birth, or the age, is not known, give your best estimate."</div><br /><br /><span class="em">6. Month of birth<br /></span><div class="i1">Fill one circle</div><br /><br /><div class="i2">[] Jan. - Mar.<br />[] Apr. - June<br />[] July - Sept.<br />[] Oct. - Dec.</div><br /><br /><span class="em">7. Year of birth<br /></span><div class="i1">Fill one circle for first three numbers</div><br /><br /><div class="i2">[] 186-<br />[] 187-<br />[] 188-<br />[] 189-<br />[] 190-<br />[] 191-<br />[] 192-<br />[] 193-<br />[] 194-<br />[] 195-<br />[] 196-<br />[] 197-</div><br /><br /><div class="i1">Fill one circle for last number</div><br /><br /><div class="i2">[] 0<br />[] 1<br />[] 2<br />[] 3<br />[] 4<br />[] 5<br />[] 6<br />[] 7<br />[] 8<br />[] 9</div><br /></svar>
