Please confirm some information about yourself:

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* 1. My first name is:

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* 2. My last name is:

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* 3. My date of birth is:

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* 4. My gender identity (sex) is:

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* 5. My home address is:

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* 6. My mobile telephone number is:

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* 7. My email is:

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* 8. I am a New York State resident.

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