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* 1. Your Name

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* 2. Your email address

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* 3. Your preferred phone number

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* 4. Location of your supervision group (city, state)

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* 5. How often does this group meet?

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* 6. If there is a recurring date/time that the group meets (e.g. first Thursday of the month), please note that here.

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* 7. Does this group meet:

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* 8. Is this group accepting new members?

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* 9. Contact information for the group

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