R E G I S T R A T I O N    F O R M

Today's Date:   Ex:  18 Aug 00
Last Name (Core):   Ex:  Banez
First Name (Core):   Ex:  Dante
Middle Name (Core):   Ex:  Sabado
Sex:   Ex:  Male
Street Address:   Ex:  P.O. Box 7307
City/Town:   Ex:  Stockton
State/Province:   Ex:  California
ZipCode:   Ex:  95267
Country:   Ex:   U.S.A.
Telephone:   Ex: 
E-mail:   Ex:  DanBanez
     
Last Name (Proxy):    
First Name (Proxy):    
Middle Name (Proxy):    
Sex (Proxy):    
Street Address (Proxy):    
City/Town (Proxy):    
State/Province (Proxy):    
ZipCode (Proxy):    
Country (Proxy):    
Telephone (Proxy):    
E-Mail (Proxy):    
     
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Revised: August 22, 2000
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