Print Your Name _____________________________________________ Date _______/_______/_______

Home Address ___________________________________________ Phone No. (         )_________________

__________________________________________________ _________ _______________
City or Town                                                                                               State            Zip Code

Business Name_____________________________________________________________________________

Address ______________________________ _______________________ ________ _____________
                Street or P.O. Box                                        City or Town                                State           Zip Code

Bus. No. (         )____________________ Fax No. (         )____________________ E-Mail ____________________________

Tell Us a Little About Yourself

Are you a:   Please Check All That Apply    
                      
                                   Consumer______     Activist______   Lobbyist______   Attorney______   Legislator______

                                   Other___________________________________________________________________

Would you like to volunteer support?
If so, please explain:_____________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Are you a denture wearer?      YES          NO        If so, are your dentures causing problems?     YES     NO

In your opinion, are your dentures causing severe problems?  PLEASE EXPLAIN:

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

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Where do you wish to receive your correspondence: Home _____ Business _____

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