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* 1. What is your Affiliate?

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* 2. Your Name

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* 3. Your Role or Title

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* 4. Phone Number

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* 5. Email Address

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* 6. Which program are you applying for funding to hold a training?

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* 7. How long ago was the last local training for this program?

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* 8. How many qualified and interested individuals do you have on your waiting list to get trained in this program?

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* 9. What are the plans to offer this program locally after a training? Please be as specific as possible regarding planned start dates, locations, partners, etc.

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* 10. How will diversity (either geographical or cultural, or both) be incorporated into this training?

Ex. This training will allow us to train individuals in a very rural area that has never received training before; This training will serve the Native American population in our city, and we will offer the program in the Native American Resource Center after we have trained program leaders.

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* 11. When can you hold this training (must be before August 2018)?

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* 12. Any comments or questions?

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