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SELF
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SPOUSE/PARTNER
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First Name(s)
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Surname
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Title
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Address
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Postcode
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How long at this address
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Telephone
Home
Work
Mobile
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Fax
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E-mail
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Date of Birth
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Marital Status
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Nationality
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NI Number
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Tax District
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Tax reference
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Current tax rate
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Current tax code
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How is Married Couples
Allowance, if any, apportioned
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Marital Status
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Is your general health
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Good/Average/Poor
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Good/Average/Poor
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Do you smoke?
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Smoker/Non-smoker
for less/more than 12 months
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Smoker/Non-smoker
for less/more than 12 months
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What is your average daily consumption of alcohol
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Do you suffer from any disability:
Temporary
Long-Term
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