BACA Registration Form

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100% of survey complete.
Address

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* 1. Address

Your date of birth

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* 2. Your date of birth

Gender.

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* 3. Gender.

Race

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* 4. Race

Do you identify with any of the following religions? (Please select all that apply.)

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* 5. Do you identify with any of the following religions? (Please select all that apply.)

Fan number

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* 8. Fan number

Licensed number

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* 9. Licensed number

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