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This form is in Spanish, so here if you don't know Spanish, here is the translation in order to fill it out correctly... though we've probably filled out enough of these forms to know it by heart! :)

Nombre = Name
Apellido = Last Name
Correo Electronico = Email Address
Confirma Correo Electronico = Confirm Email Address
Direccion 1 = Address
Direccion 2 = Address (if continued)
Ciudad = City
Estado = State
Codigo Postal = Zipcode
APLICAR = Apply