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: Mobile inc STD Code inc STD Code Work: Other ie next of Kin, Carer inc STD Code inc STD Code EMAIL ADDRESS DATE OF BIRTH Day MARITAL STATUS Month Year eg single, divorced seperated, widowed ? HEIGHT ? Feet Inhes FEET INCH DO YOU SMOKE ? DO YOU DRINK ? If yes, how many per day? If yes, how much per week? PLEASE DESCRIBE YOUR ETHNIC ORIGIN eg British, black, white, African, Asian, European, American SITS Application form V2 28.02.05 11:46 am Page 2 DATING AGENCY A.

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