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Youth Be There, Be Counted Voter Coalition Registration Form

First Name:*     Last Name:*       Preferred to be called:

Street Address:* City:* State:* Zip:*

Home Phone:* Cell Phone:* Email:*

Facebook Address: My Space Address:

Gender:* Female Male      Age:*  If other, Age:   Registered to vote:* Yes No

School (if applicable):       Place of Work (if applicable):

Issues important to you in Elections '08

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