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You can use your browser's "print" function to make a copy of this form. Then you can fill it out by hand and mail it to:
Coalition of Wisconsin Aging Groups Please make your check payable to "CWAG." Thank you! |
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First Applicant ... |
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Mr. Mrs. Ms. (circle one) |
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First name, last name:
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Date of birth:
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Second Applicant ... |
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Mr. Mrs. Ms. (circle one) |
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First name, last name:
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Date of birth:
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Joint Information ... |
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Home address (incl. city, state, zip):
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County:
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Telephone (incl. area code):
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Check the description that fits you best ... ___ Wisconsin citizen interested in helping older citizens |
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I would like to make a tax-deductible contribution to CWAG in the amount of $_________ |