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Requirement
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Submit this
information
by
phone, or e-mail
1. Married, Co-hab, or
Single: ..................................................................................................................................... 2. Your Name: 3. Spouse's name: 4. Age(s): 5. Address: 6. City, State, and Zip Code: 7.
U. S. A. Only:
8. Telephone #: 9. Fax # and E-mail: 10. Income: $40k+ __, $50k+ __, $75k+ __ 11. Card: Credit __, Debit __, or Check book __ 12. ID: Driver License __, State ID __, or Pass Port __ 13. Language: English __, Spanish __ |