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Personal Information

       
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*Form Type:        
*Full name:        
*Date of Birth:        
*E-Mail Address:        
*Address:        
*City:        
*State:        
*ZIP Code:        
*Phone:        
Employer:        
 

Partner/Spouse information

       
Name:        
Date of Birth:        
Employer:        
Anniversary:        
 

Child information

       
Your multiples are:        
Your have or are expecting:
Are you pregnant:        
If pregnant, your due date:        
*1st child name: *Gender: *Date of Birth:
*2nd child name: *Gender: *Date of Birth:
3rd child name: Gender: Date of Birth:
4th child name: Gender: Date of Birth:
5th child name: Gender: Date of Birth:
6th child name: Gender: Date of Birth:
7th child name: Gender: Date of Birth:
8th child name: Gender: Date of Birth:
 

Member Consent

       
*I hereby give my consent for PMOT to post pictures of me/my family that may be taken at PMOT functions:
   
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