FREEDOMYOU.COM  P.O. Box 42  Cannington, ON, CANADA  L0E 1E0

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Print this form and mail with a check or money order.
Make checks payable to Freedomyou.com.

(Please Print Clearly)

DATE _______________________________


NAME __________________________________________________________________________________


STREET ADDRESS _______________________________________________________________________


                                    ______________________________________________________________________


CITY _____________________________________________________  STATE  ______________________


ZIP CODE _______________________________________   COUNTRY ____________________________


TELEPHONE ________________________________________  


EMAIL (please print clearly)  _______________________________________________________________