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FAX ALL PAGES TO WDI AT:Regency Bluesier Mail form to: PO Box 1271 Portland, OR 972071271 2069735202 Fax to: 18663035117Application For Enrollment/Change (150)Please print in black ink. Incomplete

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Fax all pages to a designated number or recipient.

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Simply fill out the cover sheet with the necessary information and attach the documents to be faxed.

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