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Civic/Church Program Request
Name of Organization:
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Contact Name:
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Phone Number:
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Email:
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Address:
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Home:
1st Priority: Requested Date & Time:
*
2nd Priority: Requested Date & Time:
*
Directions to event:
Anticipated number of attendees (enter a number):
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Program Requested:
About JCPB
GreenPower
PlantToPlug
SavingEnergy/Living Green
Other
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Additional Comments:
I confirm that all information provided on this form is correct and current.
