GASCCP Coordinator Registration Form

Please complete this form by no later than September 21, 2018. The coordinator listed on this form will be the primary point of contact for your agency during the 2018-2019 GASCCP campaign. The GASCCP campaign will run beginning October 1 thru October 31, 2018. Your payroll administrator is essential because they are the main point of contact for payroll deduction

State Agency/University Name

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* State Agency/University Name

State Agency/University Code

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* State Agency/University Code

Organization Type

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* Organization Type

Name of Person Submitting this form

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* Name of Person Submitting this form