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Please print the form and mail to:
TAI, William "Bill" Campbell Chapter
P.O. BOX 8814
Emeryville, CA 94662-0814
| Name of person making request: | First:
Last: |
| Name of organization making request: | |
| Requester's office phone: | |
| Requester's office fax: | |
| Organization's mailing address: |
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| Address Presentation to take place: | |
| Number of people in attendance: | |
| Age group of people at presentation: | |
| Date of presentation: | |
| Start time: | |
| Will honorarium be donated? | |
Message:
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