Application for Participation in Police/Community Mediation Project
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First Name:
Last Name:
Job Title:
Company Name:
Work Phone:
Home Phone:
Email Address:
emailaddress@xyz.com

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I ____________________________________(name of applicant) understand the responsibilities and I am committed to participating in the Planning Committee Meetings.

 

 

By checking this Box, you certify that you agree with the above statement.
By checking this box, you decline participation.
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