Please complete all items below.  

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. What is your organizational affiliation?

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* 4. What is your organizational address, including zip code?

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* 5. At what email address would you like to be contacted?

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* 6. With which GLR Network community and state are you affiliated?  (If NONE or NOT SURE, enter the response that applies.)

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* 7. What is your primary role in the GLR Campaign?

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