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 <blockquote>
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<tbody>
<tr>
<td align="right" height="11" width="392" bgcolor="#000080" bordercolor="#FF9933" valign="bottom" colspan="5">
<p align="center"><font size="1">    </font><font face="Arial" size="3" color="#FFFFFF"><b>FREE
AEROMEDICAL CONSULTATION</b></font>
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</tr>
<tr>
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<p align="right"><b><font face="Arial" size="2" color="#FFFFFF">Question</font></b>
</p>
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<td align="right" height="11" width="1" bgcolor="#FF9933" bordercolor="#FF9933">
<p align="center"> </td>
<td height="11" width="248" bgcolor="#FF9933" bordercolor="#FF9933">
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<textarea cols="30" name="Request" tabIndex="3" rows="1"></textarea></p>
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<p align="center"><strong><input name="Medical Practice Test" style="background-color: #FF9933; font-family: Arial; font-weight: bold; color: #0000FF; border-style: outset" tabIndex="13" type="submit" value="Submit"></strong></p>
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<p align="right"><font face="Arial" size="2" color="#FFFFFF"><b>E-Mail</b></font>
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</td>
<td height="11" width="248" bgcolor="#FF9933" bordercolor="#FF9933" valign="top">
<p align="left"><strong>
<input name="Email" size="35" tabIndex="4">
</strong></p>
</td>
<td height="11" width="82" bgcolor="#FF9933" bordercolor="#FF9933" valign="top">
<p align="center"><font face="Arial" size="1" color="#FFFFFF">
<a href="http://www.leftseat.com" style="text-decoration: none">
<font color="#FFFFFF">LEFTSEAT.com</font></a></font>
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