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Application

Form

Dr. Dean and Keitha Thomson
Team Leader
s

 

 

 

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Please print this form complete the requested information, enclose a check for $600.00 or a credit card number and expiration date and forward to:

Dean and Keitha Thomson
708 Centennial Ave
Nebraska City, Nebraska,  68410
402-873-7889...home (evenings)
402-873-7660.....daytime
drthomson@alltel.net

 

 

Name:..................................................................................................................
(legal name please)

Name I like to be called:....................................................................................

Street Address:................................................................................................

City, State and Zip:.............................................................................................

Phone:..................................................................................................................

email......................................................................................................................

Sometimes we are able to obtain T-shirts for the team.   In case that happens:

T shirt size...............................................................................................................

Profession, interests, talents: .......................................................................................................................

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