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2. 
4. Name
5. Email Address
7. Address
9. City
10. State
11. Zip Code
13. Phone Number
17. Favorite color

    Please type your favorite color in the box above.

18. What is your favorite season and why?
20. What is your favorite flavor?

    Please check off all that apply.

    1. Chocolate
    2. Vanilla
    3. Strawberry
21. What month were you born in?
    -- Select One --JanuaryFebruaryMarchAprilMayJuneJulyAugust
23. Email Address
24. What is your date of birth?
    What is your date of birth?

    What is your date of birth?
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26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

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