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Unformatted text preview: B US 595 – Spring 2010 | I nformation Form P a r ticipant We require that everyone complete this form and return it by N ovember 15, 2009 t o Rosanna Koppelmann along with another payment of $1,000 payable to “WMBSF.” Full Name (as printed on passport): Surname (last n ame):___________________________________________________________________ Given Name (Fi rst/Middle n ames):________________________________________________________ Count ry of Citizenship: __________________________________________________________________ Passport Details: Passport No. ________________________________ Date of Bi r th ______________________________ Date of Issue:________________________________ Expi ration D ate:____________________________ Place of Issue:________________________________ I f Non-U.S. Resident, Visa Status (Student, Green Card, e tc.)____________________________________ Address (Cu r rent address must be a Vi rginia address): Street Address (NO PO BOX): _____________________________________________________________ C ity:___________________________________________ State:_____________ Zip code:____________ Phone (W) ___________________________ ( H) ________________________ ( Cell):________________ Email:_______________________________________________________________________________ Please make sure your passport is valid for at least 6 months after your return to the U.S. ...
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This note was uploaded on 02/05/2011 for the course BUAD 500 taught by Professor Wilson during the Spring '11 term at William & Mary.
- Spring '11