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 Country         Date of Birth

Costeño by: Birth Marriage  Descent

Citizenship:    Nicaraguan  U.S.A

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I understand that by filling out this form that I automatically become a member and agree to support the visions and goals of Costeños Unidos Pro Desarrollo de la Costa Atlántica de Nicaragua, always within the limitations of my time, resources, and finances. I also understand that there are no legal obligations.