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* 1. What is your first and last name?

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* 2. What is your email address?

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* 3. What is your phone number?

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* 4. What is your street address?

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* 5. What is your postal code?

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* 6. Which FoodCycler model would you like to purchase for your household?

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* 7. I acknowledge that by participating in this pilot program and obtaining a municipally subsidized FoodCycler, I am required to track usage for 12 weeks and complete a brief exit survey about my experience with the program.

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