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* First Name:

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* Last Name:

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* Street Address:

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* City:

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* Zip Code:

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* Birth Date:

Birth Month / Date / Year

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* Phone Number:

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* Email Address:

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* Would you like to receive the Twelve Oaks Mall weekly email?

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* Were you referred to the Twelve Oaks Mall Walker program?

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* If you were referred, by whom?

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* Please check here to indicate that you know that your Membership Card will be waiting for you.

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