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 The recipient of this form in no way obligates Mark A. Douglas P.A., Attorneys at Law, its associates or its affiliates to provide legal representation to the above-listed individual. The information being received is for informational purposes only and legal representation is not guaranteed nor is any attorney client relationship created until a written contract is signed between Mark A. Douglas, P.A. and the potential client. Additionally, Mark A. Douglas, P.A. reserves the right to refuse legal representation to the above-listed individual at its sole discretion.