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Tell Me Something About You....

 

Please provide the following contact information: (You may skip some of the option). If the questions is not applicable, leave it in blank.

First name
Last name
Middle initial
Title
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
Home Phone
FAX
E-mail
URL

Please identify and describe yourself: (OPTIONAL) If you wish to provide answer following. If it is not necessary, then leave it as it is..

Name
Age
Sex Male Female
Hair color
Eye color

Select any of the following options that apply:

Have you ever fallen in love?

Would you like to know why I am asking your personal question ?

Yes No

Enter the date of landing Jashim's indegious page:

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Enter the time of landing my cyperspace ... :

-- hh:mm:ss am/pm

How would you rate your opinion of this page ... ?


How many times have you visited this web ... ?


Enter your favorite things ... in the space provided below.


Any suggestion for Jashim ... ?



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