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GoldMine Import Template 1
Name
*
E-mail Address
*
Work Phone #
Home Phone #
Cell Phone #
Address
*
Apt/PO Box/Suite #
City
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State
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Alabama
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Louisiana
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Maryland
Massachusetts
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Ohio
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U.S. Territories
Guam
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Federated States of Micronesia
Northern Mariana Islands
Marshall Islands
Palau Islands
Puerto Rico
US Virgin Islands
Canadian Provinces
Alberta
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Manitoba
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Northwest Territories
Nova Scotia
Ontario
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Quebec
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Yukon Territory
Other or None
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Zip Code
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How did you hear about us?
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Notes/Concerns/Comments
Gender
County
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Birthdate
Medicare Number (no dashes)
Part A Eff. Date
Part B Eff. Date
Current Medicare Plan (if any)
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