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O. Box 728 Burlington IA 52601 Phone 319-753-9136 e-mail jwalz tworiversbank. com Name last Address first middle street city/st/zip Birth Date Place of Birth Cell Phone Home Phone Yes No I attended high school in one of the following Iowa counties Des Moines Lee Henry or Louisa CIRCLE COUNTY My primary residence is in one of the following Iowa counties I will attend one of the following colleges or universities Southeastern Iowa Community College Iowa Wesleyan College University of Iowa...

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