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Enclosed
is my check for:
___ $35* ___
$50 ___ $75 ___ $125 ___ Other
*(please give
this amount or more if you possibly can)
Member
Information
Name:___________________________________
Address:_________________________________
City:__________________________ State:_____
Zip:________________
Home phone:
(_____)________________
Office phone: (_____)________________
E-mail:____________________________
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