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* 1. Provide the following information

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* 2. What is your age?

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* 3. What is your race?

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* 4. What is your gender?

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* 5. How many people live in your household?

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* 6. What is your housing status?

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* 7. What is your martial status?

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* 8. What is your source of income? (Check all that apply)

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* 9. What is your annual income?

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* 10. How far did you go in school?

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* 11. Would you like help with these job related activities? (Check all that apply)

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* 12. What services do you need from FACAA? (Check all that apply)

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* 13. What are the greatest needs in your community? (Check all that apply)

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* 14. Do you have Health Insurance?

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* 15. Who is your Health Insurance Provider? (Check all that apply)

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* 16. Are you a veteran?

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* 17. Are you receiving veteran benefits?

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* 18. Are you a registered voter?

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* 19. Overall, how satisfied or dissatisfied are you with our service?

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* 20. If dissatisfied, please state the reason why.

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