Last Name :________________________ Year of birth:_________________
First Name:_________________________ Age this year:_________________
Address:_________________________ Religion:_________________
:_________________________ Occupation:_________________
City:_________________________ [ ] Male [ ] Female
State:_________________________ [ ] Single [ ] Married
Country:______________ Postal Code:___________Email Address:_________
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Correspondance Preferred [] Male [] Female [] Both
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25[]Travel
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Region 6 [] Eastern Europe ALL [] All Regions
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