Dining Out For Life Activation Form 2017

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(Maximum response 255 chars, approx. 5 rows of text)

2. Restaurant contact information

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Name:

 

 

   

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City/State/ZIP:

 

    

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If you respond and have not already registered, you will receive periodic updates and communications from The Center.

 

 

What's this?

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(Maximum response 255 chars, approx. 5 rows of text)

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Question - Not Required - What online services do you belong to?

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Question - Required - Location Type

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