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* 1. First name 

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* 2. Last Name

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* 3. Address

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* 4. City

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* 5. State

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* 6. Zip Code

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* 7. Birth Date

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* 8. Phone Number 

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* 9. Email Address 

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* 10. Would you like to receive email communications regarding stores, products, services and other information? 

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* 11. I understand my membership card will be available for pick up at the next scheduled Mall Walking breakfast meeting. 

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