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BACBO Intake Form
General Information:
*
1.
Information
(Required.)
Name of House of Worship:
Street Address:
City:
Zip Code:
Clergy Leader:
Clergy Leader Title:
Clergy Leader Position:
Email Address:
Phone Number:
Fax Number:
Website:
*
2.
Key Contact Information
(Required.)
First Name:
Last Name:
Phone Number:
Fax Number:
Mailing Address [If different from house of worship address]:
City:
State:
Zip:
Current Progress,
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