| *First Name: |
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| *Last Name: |
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| *Street Address: |
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| *City: |
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| *State: |
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| *Zip: |
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| *Phone (AreaCode-xxx-xxxx): |
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| *E-Mail Address: |
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| *Amount Paid by Check (written to "AGE") or Cash: |
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| *Check Number or "Cash": |
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| *Date Paid: |
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*Are you using Loyalty Program Credit? (details) |
Yes
No
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*Do you give permission to AGE to use your name, photograph, and the story of your experience as a participant in AGE programs for the purpose of promoting the programs? |
Yes
No
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*Have you attended an Austin Computer Learning Center (or SeniorNet Austin) Course before? |
Yes
No
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*For the purpose of obtaining grants, please select your age group: |
50-59
60-69
70-79
80+
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| *Gender: |
Male
Female
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*Indicates required field (Please help our staff and fill in each and every field in the above form.) |
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