Customer Registration

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Customer Registration
Fields marked * are mandatory.    
*First Name:  
*Last Name:
Gender:     
* D.O.B: 
(MM/DD/YYYY)  
*Country:     
*State:  
*City: 
*Email: 
*Secret Question: 
*Your Answer: 
*Password: 
(6 alphanumeric characters,one character must be numeric)
*Re-type Password
    Terms of Use: 
 
Code
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* Code: 
(Case sensitive)