Mums Lounge Modibodi Reviewer Application

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* 1. Please tell us the following:

First name

Last name

Email address

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* 2. Please tell us your age:

18-24

25-34

35-44

45-54

Other (please specify)

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* 3. Please tell us your daughter's age:

8-10

11-13

14-16

17-19

Other (please specify)

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* 4. Please tell us your location:

QLD

NSW

VIC

SA

WA

ACT

NT

TAS

Other (please specify)

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* 5. If you are selected as one of our Mums Lounge reviewers, you will be required to provide us with feedback on the Modibodi products you receive that will be published and agree to a list of terms and conditions that will be provided upon selection. Do you agree to do so if you are selected?

Yes

No