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Please Fill Out Form in Full



Address (number, street, city, province, postal code)

Phone (home and/or cell)

Full Birth Name (Include Middle Name)

Public Name (the name you are currently using)

Additional Surnames (Include Surnames you have had while with a partner, even if you did not take the Surname of your partner, please include)

Nicknames and/or Abbreviations of Name (who they were given by and at what age)

Legal Name (how you sign documents, if different than above)

Adopted Name (aware of Birth Name before second given name)

Full Birth Date

Physical Symptoms (past, present, chronic - gives you more information, as to how your Body, your Life is speaking to you)

Reason for your interest in Personal Research