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                               Hacker's club ID:

                                         First name:

                                         Last name:

                                           Address:   

                                           Country: 

                                         City/state:  

                                          Zip code: 

                                   Date of birth :  jan feb mar apr may jun jul aug sep oct nov dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 (mm/dd/yy)

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                                        Password: 

                      Re-conform password: