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2. Organization Name*
4. Description
   Please share either the service offerings of your organization or its mission statement.
6. Contact Name
8. Address*
10. City
11. State
12. Zip Code
14. Phone Number*
15. Fax Number
17. Email Address
19. Website
21. Proof of Non-Profit Status*
    Please upload proof of your organization's non-profit status, such as a 501(c) Affirmation Letter.
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23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit

* indicates a required field