Date:
Name of Organization:
Street Address:
City:
State:
Zip:
County:
Contact Person:
Title:
Daytime Phone:
Fax:
Email: *Required	(Ex: email@yoursite.com)
Topic for Workshop:
Requested Workshop Location:
Organization Mission:
Agency Status:
501(c)(3) 501(c)(4) Other: Advanced Ruling Permanent Application
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