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<FORM action="http://pub18.bravenet.com/emailfwd/senddata.asp" method="post">

<INPUT type="hidden" name="usernum" value="1534081586">

<INPUT type="hidden" name="cpv" value="1">

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What is your name?<BR>

<INPUT type="text" name="name" size="20"><BR>

Where are you from?<BR>

<INPUT type="text" name="where" size="20"><BR>

E-mail address?<BR>

<INPUT type="text" name="replyemail" size="20"><BR>

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<INPUT type="submit" name="submit" value=" Send ">

<INPUT type="reset" name="reset" value=" Clear "><HR>

<A href="http://www.bravenet.com/">

<IMG src="http://images.bravenet.com/brpics/formbutt.gif" border="0" width="100" height="35"></A>

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