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2. 
4. First Name*
5. Last Name*
7. Address*
9. City*
10. Zip Code*
12. Phone Number (home)
13. Phone Number (cell)
15. Email Address
16. Are you over 18?*

    1. Yes
    2. No
18. Political Party*
    -- Select One --DemocratRepublicanIndependentNo party designated.
19. Languages spoken in addition to English
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