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* required fields
name: * postal code:
address: phone:
city: fax:
province: email: *

questions and comments: *
Enter the security code below: *

Guess the letters and numbers
(passphrase riddle)
--
3 chars before small Q
followed by
small 'U' +3 letters
;
2 chars before small Y,
small 'Q' +2 letters
and
(??? - 2) = -1
and then