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- Address*
  Street Address City State / Province / Region ZIP / Postal Code Country
- Phone*
- Work or Alternate Phone number
- Are you currently taking KoBu Power? If so, where?
- Do you have any Health or Fitness concerns?
- Have you ever tried Kickboxing before or any other related workout or education? Any other info you would like to share?

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		Product	Price	Quantity	Total
×		KoBu Power DVD	$29.00	Quantity	$29.00
×		Kidini Book & Music CD	$20.00	Quantity	$20.00
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Cart totals

Subtotal	$49.00
Total	$49.00

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