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: Street address: City: State: Zip: Home Phone: Work Phone: Cell Phone: E-mail address: Marital status: Never married Date of birth: / Married / Separated Age: Divorced Gender: Have you accepted Jesus Christ as your Lord and Savior? Yes Widowed Male Female No Do you believe Jesus Christ was conceived of the Holy Spirit and born of the Virgin Mary? Yes No Do you believe Jesus Christ was crucified and died, was buried, rose again on the third day and is now seated at Yes .

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