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test signup form with country and province

Company
First Name*
Last Name*
Email address*
Address*
Apt, unit, bldg, fl ...
City*
Country*
Prov/State*
ZIP/Postal Code*
Phone Number*
Phone Ext
Username*
Password*	Passwords must be between 8 and 128 characters Very Weak
Confirm password*
Optional field


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Phone

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