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Registration Form
Please print this form with your web browser, complete the form, and mail to the address below.
Last Name ________________________________
Husband's First Name ____________
Wife's First Name ________________
Address __________________________________
City _____________________
State __________ Zip ___________
Home phone _____________________
Work phone ______________________
(husband's or wife's?)
Number of years married _________
Number of children ___________
Religious affliliation __________________
Date of Encounter desired __________________
Alternate date ___________________
Smoker Non-Smoker
Names of friends who have made an Encounter:
_____________________________
_____________________________
Address Phone
Please mail this completed application plus a $25 deposit to:
St. Cloud National Marriage Encounter
P.O. Box 635
St. Cloud, MN 56302
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