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* 1. Please provide your first and last name.

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* 2. Please provide the name of your entity/organization, if applicable.

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* 3. Please provide your address.

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* 4. Please provide the address of your entity/organization, if applicable.

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* 5. Please provide your telephone number, mobile number, and email address.

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* 6. What is your preferred method of contact?

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* 7. Select which group(s) you would like your information provided to.  Please select all that apply.

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* 8. Please select the county that you are most interested in working or operating in (you can select up to five (5) counties)?

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* 9. Please click here to download the JVPP authorization form. Once downloaded, please fill it out and email it to mra-socialequity@michigan.gov. Once you have emailed the authorization form, please click YES to continue.

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