| 1. |
Have you participated in the Hot Shots for Tots campaign before?
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| 2. |
Contact Information
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| 3. |
List the name and address for each facility you would like to enroll.
| Facility 1 | An answer is required | An answer is required | An answer is required | An answer is required | An answer is required | An answer is required | An answer is required | An answer is required |
| Facility 2 (if applicable) | An answer is required | An answer is required | An answer is required | An answer is required | An answer is required | An answer is required | An answer is required | An answer is required |
| Facility 3 (if applicable) | An answer is required | An answer is required | An answer is required | An answer is required | An answer is required | An answer is required | An answer is required | An answer is required |
| Facility 4 (if applicable) | An answer is required | An answer is required | An answer is required | An answer is required | An answer is required | An answer is required | An answer is required | An answer is required |
| Facility 5 (if applicable) | An answer is required | An answer is required | An answer is required | An answer is required | An answer is required | An answer is required | An answer is required | An answer is required |
Your entries do not add to the required value
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| 4. |
Do you have any questions or comments on the campaign at this time?
| An answer is required | |
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