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* 1. First Name:

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* 2. Last Name:

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* 3. Home Address:

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* 4. Phone Number:

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* 5. Email Address:

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* 6. What experience, if any, do you have with conflict resolution?

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* 7. What experience, if any, do you have with community/police engagement?

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* 8. How would this dialogue be meaningful for you?

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* 9. Is there anything else you would like to share?

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