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* 1. What is the name of your organisation?

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* 2. How many members or participant do you have?

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* 3. Who is to be our point of contact?

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* 4. Phone:

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* 5. Email:

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* 6. What amount would you like to request:

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* 7. What would this help you achieve?

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* 8. Is timing of these funds important?

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* 9. If yes, please provide details:

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