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Ddress City, State, Zip Code Telephone Number Permanent Address (must be CO address) City, State, Zip Code Telephone Number (permanent) E-mail Address Date of Birth Birthplace Gender Marital Status Where did you hear about WICHE PSEP? Ethnicity question is optional. Please circle one. American Indian/Alaskan Native Asian/Pacific Islander Black Hispanic White Colorado Resident Information: Dates of continuous physical presence in Colorad.

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