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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)
--
2 chars before small Z
and then
small 'H' +2 letters,
small 'F' +2 letters
followed by
small 'D' +2 letters
;
1 chars before small G
followed by