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* 1. What is your full name?

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* 2. What is your mailing address (for shirts, giveaways, etc). Please include city, state, and zip code.

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* 3. What is your mymdc.net email address?

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* 4. What is your student ID number?

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* 5. What is your phone number including area code?

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* 6. Please select your membership interest.

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* 7. If you are interested in a leadership position, please indicate the best day(s) and time(s) to call you. Please write N/A if this is Not Applicable.

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* 8. What club(s) are you representing as a delegate to SGA/ICC? Write N/A if Not Applicable.

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* 10. By checking the first box, you are affirming that you have read and agree with the below statements.

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