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First Name:	*	Last Name:	*
Email:	*	Phone:	*
Address:	*	Apt#:
City:	*	State:	*
Zip/Postal Code:	*	Country:	*

Date of Birth:	/ /	Work/School Name:

What skateparks do you frequent most?
Skatepark #1		Skatepark #2
Skatepark #3		Skatepark #4

What skate shops do you buy from most?
Shop #1		Shop #2
Shop #3		Shop #4

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