v∙¾†¨€ zÆÃÁ€†ˉ¸ÃŒı (Type or print in ink only, NO PENCIL) Name _____________________________________________________________ (First) (Middle) (Last) Name you want to be used in publications ________________________________ Home address ______________________________________________________ (Street address) ______________________________ ______________________ (City, State) (Zip) Phone Number _________________________ __ Home __ Cell __ Other Email _____________________________________________________________ Birthdate _________________________ Male ____ Female _____ Parents/Legal Guardian Information: Father's Name & Address _____________________________________________ Phone _____________________________________________ Mother's Name & Address ________________________________________电话________________________________________________________________________________________________十
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