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Name: Title: Address Phone Number Web site Address Overview of what your services are. _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ This is a free service, all we ask is that you print this off, and mail back to me. Also that you hold Lester J. Robinson III, and the website www.wnyinsurance-quote.com free of any copyright laws, or any unauthorized materials, and you release me from any problems that may happen in anyway do to your business or service. At any time you may be remove from website, with any notification. Or E-mail information to Healthlistings@aol.com
______________________________________ Name _______________________________________ Address/State/Zip _________________ Date
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