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                 Last Name:
             Date of Birth:
            Street Address:
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                      City:
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              Zip Code Ext:
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                   Product  Price Total
                   -------- ----- -----
                   WAPSWGT    $10
                   WAPSVAL    $10
                   WAPSCALC   $10
                                  -----
                   Grand Total:

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                            UserWare / Shazam Software
                            4 Falcon Lane East
                            Fairport, NY 14450