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Request For Member Education In-Service

Contact Information


First Name    Last Name


City     State      Zip

Phone     E-mail

When (date requesting)?            

Time: From To

Other Agencies attending

Who will be attending (e.g., social workers, outreach workers) & How Many?

Issues that you want reviewed

Purpose of in-service

Note: Once requested form is received, a member education representative will follow up with you.