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2. First Name*
3. Last Name*
5. Email Address*
6. Phone Number*
8. Date and Time of Event*
   Date and Time of Event

   Date and Time of Event
9. Event Location*
11. Event Summary*
12. Cost to attend*
14. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
16. Electronic Signature
Leave This Blank:


18. Submit

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