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* 1. Please explain how RLS has impacted your life and why more RLS research is needed: (in approximately 150 words or less)

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* 2. Do you give the RLS Foundation permission to use your story in letters to legislators requesting more funding for RLS research?

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* 3. Name:

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* 4. Address:

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* 5. City:

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* 6. State:

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* 7. Zip:

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* 8. Email address:

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* 9. Telephone number:

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