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Questions regarding this request form should be directed to Carol Cole at colecj@dhfs.state.wi.us.

* 1. What are you requesting?

2. If other, please describe.

* 3. For which topics are you making this request?

* 4. Which agency or organization do you represent?

* 5. What type of agency is this?

* 6. Is there a specific date by which you need this information?

7. What is the date by which you need this information?

* 8. Is this for a specific event?

9. If yes, what is the event?

* 10. What is the size ot the intended audience?

11. Is there anything else you feel we should know about this request, your agency, or your event?

* 12. How we can contact you? Please give us your name, telephone number, and email address.

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