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* 1. First and Last Name

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* 2. Company (if applicable)

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* 3. Title (if applicable)

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* 4. email address

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* 5. Mailing Address

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* 6. Telephone number

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* 7. Total amount pledged for 2022

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* 8. The contribution will be made by

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* 10. Do you have any additional questions or comments?

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