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CUSTOMER REGISTRATION



	Personal details:
	Title:*
	Surname:
	First Name:*
	Middle Name:

	Contact details:
	Address:*
	Address:*
	City:*
	State:*
	Country:*
	Telephone Number:*
	Cell Phone number:
	Email:*

	Account details:
	Username:*
		(Start with a letter, No space allowed in your username, more than 5 characters)
	Password:*
	Re-Type Password:*