Appendix 1 Part B

Facilitator application: Each individual applicant must complete and submit along with the employer authorization (Appendix 1 Part A)

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* 1. Name:

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* 2. Educational Entity/Agency Name:

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* 3. Please check which Facilitator level you are applying for:

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* 4. Indicate work affiliation:

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* 5. Counties the educational entity/agency works in:

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* 6. Work Contact Information:

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* 7. Please list a home email address if you work at a school or organization where you are not available at the work address given above during the summer months. Year-round, preferred email address:

Question Title

* 8. Signature

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