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* 1. UVA Affiliation

* 2. First Name

* 3. Last Name

* 4. Email Address

* 5. Local Phone Number

6. Home Phone Number

* 7. Local Address

8. Home Address

9. Make of Bicycle/Scooter

10. Model of Bicycle/Scooter

* 11. Bicycle/Scooter Serial Number

12. Bicycle/Scooter Color and or Description

13. Bicycle/Scooter Value

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