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Date
First Name Last Name
Date of Birth   (h) Phone  (c) Phone
E-Mail   
Address #1
Address #2
City   State ZIP
Parents
Grad. Year   Est. GPA   ACT   SAT

Current High School

Current College/JC   

  

1727 W. Alabama
Chickasha, OK  73018-5322
(405) 574-1358 Fax (405) 574-1220

 

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