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* 1. Email address of owner (this is your agency's ELGL Administrator, not your personal email address)

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* 2. Your email address

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* 3. First Name

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* 4. Last Name

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* 5. Birthday

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* 6. Organization Name

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* 7. Job Title

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* 8. Phone

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* 9. Street Address

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* 10. City

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* 11. State

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* 12. State

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* 13. Zip Code

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* 14. Facebook profile

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* 15. Twitter handle

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* 16. LinkedIn profile

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* 17. What population does your position serve?

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* 18. Please select your ethnicity.

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* 19. Please select your gender (note that cisgender refers to identifying with the gender with which you were born):

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* 20. Please select your age range:

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* 21. What type of organization best describes your current position?

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* 22. Undergraduate institution and degree (optional)

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* 23. Graduate institution and degree (optional)

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* 24. How did you hear about ELGL?

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