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* 1. What is your first and last name?

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* 2. Which state do you represent?

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* 3. What is your email address?

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* 4. What is your phone number?

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* 5. What was the date of your ambassador activity?

Date

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* 6. Select the type of activity conducted:

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* 7. What was the name of the event or group?

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* 8. Please provide a brief event description:

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* 9. What was the total number of people in audience (if actual number not known, please estimate):

T