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Submitted URL: http://dtc.jotform.com/241076056960053
Effective URL: https://dtc.jotform.com/241076056960053
Submission: On December 20 via manual from US — Scanned from US
Effective URL: https://dtc.jotform.com/241076056960053
Submission: On December 20 via manual from US — Scanned from US