Citizen / Supporter Application Form

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Please fill in the information below:
Citizen / Supporter - $35 * Please select the citizen / supporter option.
Contact First Name:	* Please enter a valid first name.
Last Name:	* Please enter a valid last name.
Address:	* Please enter address.
City:	* Please enter a city.
State:	* Please select a state.
ZIP Code:	* Please enter a valid ZIP code.
Phone Number:	* (xxx-xxx-xxxx) Please enter a valid telephone number.
Email Address:	* Please enter a valid email address.
Tell us how you heard about Dane Buy Local:
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I want to receive the weekly Dane Buy Local Buzz e-Newsletter * Please select the receive the weekly Dane Buy Local Buzz Newsletter.
Dane Buy Local reserves the right to decline membership to any entity that, in the sole discretion of Dane Buy Local, is not in accordance with the spirit or mission of Dane Buy Local.
Date:	* Please select the date.
Please make check payable to Dane Buy Local and remit to: Dane Buy Local c/o Drake & Company 660 W. Washington Ave., Suite 300 Madison, WI 53703 Please direct all questions to Ms. Lark Paulson, Director of Membership Services, at 608.467.7555 or lark@danebuylocal.com.
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