AFT New Mexico | 530 Jefferson St. NE. Albuquerque, NM 87198 | 505-266-6638 |

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* 1. Address

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* 2. Higher Education Institution (you are completing your student teaching through):

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* 3. Approximate Start Date:

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* 4. Years of Coverage

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* 5. Date: 

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* 6. Signature:

By entering your full name in the box above, you affirm that the information entered above is complete and accurate so that your liability insurance application may be processed correctly. 
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