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First Name*

Last Name*

E-mail*

Mobile (optional)

Home Address*

City*

Postal Code*

What issues matter the most to you, and how can an Advisory Council help with these issues?

Interested Advisory Council:

I would like to be a part of this opportunity and join the Hastings-Lennox & Addington Advisory Council selected above

Please type your name as your signature*

Date Signed*: