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A division of
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Sister Cities International
General Exchange |
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Please enter the information below and click submit. |
| First Name | |
| Last (Family) Name | |
| Sister Cities Group: | |
| Home address | |
| Address (cont.) | |
| City | |
| State | |
| Zip Code | |
| Home Phone | |
| Fax Phone | |
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email is an efficient way to contact you |
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Please wait while your information is being sent...
Please do NOT press "Submit Form" more than once!
IMPORTANT: Coverage will be effective the date the correct premium is received by the Company or a representative of the Company or the effective date of the coverage period, whichever is later. Coverage will be effective the date the correct premium is received by the Company or a representative of the Company or the effective date of the coverage period, whichever is later. By submitting this form electronically, the student acknowledges the following: (1) he/she has carefully read the plan description and elects to enroll as indicated on this enrollment card; (2) Rates are not pro-rated other than as listed on this enrollment card; (3) he/she meets the eligibility requirements for this coverage as described in the plan description; (4) If it is later determined that the student is not eligible, the premium will be refunded; and (5) Other than eligibility, the premium is not refundable.
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