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* 1. Last Name 

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* 2. First Name 

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* 3. Email Address 

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* 4. Address 1

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* 5. Address 2

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* 6. City

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* 7. State

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* 8. Zip Code 

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* 9. Contact Telephone or Cell Number

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* 10. How did you hear about the November 3rd Veterans Day Clinic?

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* 11. Please tell us if you are interested in attending a know-your-rights presentation in the following areas. Please choose three and rank them 1 (most interested) to 3 (least interested).

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* 12. How will you travel to the November 3rd Veterans Day Clinic?

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