DATE

PLACE

FAMILY NAME

GIVEN NAME

DATE OF BIRTH

PLACE OF BIRTH

NATIONALITY

SEX

HEIGHT

HAIRS

COLOUR OF EYES

STATUS

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ROAD, NUMBER:

CITY:

STATE:

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FACSIMILE:

CELL PHONE:

E-MAIL:

NAME OF REFERENT ORGANIZATION:

ADDRESS OF REFERENT ORGANIZATION:

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P.O.BOX:

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NAME OF PRESIDENT (OR EQUIVALENT) :

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FAX NUMBER:

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