Trusted Form

Lead Verification Details

Securely captured and verified lead information

This lead has been verified and consent recorded.

Contact Information

First Name

Ronald

Last Name

Roman

ZIP Code

14850

State

NY

Date of Birth

1956-12-05

Verification Log

TokenLT-MVFRIZLM-L5ZMKY
Submitted10/19/2026, 9:24:50 PM
IP Address58.65.217.146
Time on Form163s
Consent✓ Recorded