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<form action="/cgi-bin/mailback.pl" method="POST">

<p>Please fill in the following information:</p>

<p>Customer's Name: <input type="text" name="CustomerName" size="60"></p>
<p>Street Address: <input type="text" name="StreetAddr" size="40"></p>
<p>City, Province: <input type="text" name="City" size="40"></p>
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