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P.O. Box 58 Wildwood GA 30757 Phone: +1 (706) 8209804 www.lightingtheworld.org info lightingtheworld.org Fax: +1 (706) 8201474 MEDICAL HISTORY & EXAMINATION FORM 1. Name: Sex: Age: 2. Race: Birthplace:
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The purpose of Box 58 Wildwood GA is to gather specific information related to tax reporting.
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