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2) Send it in with payment to:
Mark Evans
1831 Riverside Drive
Berlin, NH 03570
Name: _________________________________________________________
Street: _________________________________________________________
City: ___________________________ State: __________ Zip: ________________
Phone Number: __________________________
Please check the box that appliesr:
__ Insurance 101 ($150 on or before January 28)
__ Insurance 101 ($135 on or before January 28 with AAC membership)
__ Insurance 101 ($180 after January 28)
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__ Check Enclosed __ Master Card __ Visa
Card Number ________ - ________ - ________ - ________ Expiration Date _____ / _____