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* required fields
name: * postal code:
address: phone:
city: fax:
province: email: *

questions and comments: *
Enter the security code below: *

Guess the letters and numbers
(passphrase riddle)
--
(((??? / 4) - 10) * 8) = -76,
1 chars before small F
and then
small 'D' +1 letters,
0 chars before small V
&
small 'X' +2 letters
and then