Basic Coalition/ Organization Info

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* 1. What is the name of your coalition / organization

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* 2. What county (counties) does your coalition/ organization serve? (If Applicable)

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* 3. What is the approximate population of the county (or counties if applicable) your coalition/ organization serves?
If counties- please list individually with populations

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* 4. What city (cities) does your coalition/ organization serve? (If applicable)

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* 5. If you just cover a city and not an entire county please let us know the population of the city (cities)
(If you answered the question about county population you do not need to answer this question)
If listing multiple cities please list them individually and provide the population.

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* 6. Coalition mailing address, phone and email

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* 7. Coalition/ Organization Website- If you have one.
By providing this information you give AC4C permission to link your page to our website.

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* 8. Do you have a facebook page?

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