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Nafn_________________________________________________________________________________
Fæðingardagur_______________________________Ár________________________________________
Heimilsfang_________________________Póstnúmer___________________________________________
Tölvupósfang___________________________________________________________________________
Sími___________________________Vinnusími_______________________________________________
Skóli__________________________________________________________________________________
Nafn forráðamanns_______________________________________________________________________
Systkini_________________________________________________________________________________
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Staður _______________________________________________ Dagsetning ______________________
