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* 1. Your First and Last Name

* 2. What is your date of birth (month and day only)?

* 3. What is your spouse's/significant other's date of birth (month and day only)?

* 4. What is your spouse's/significant other's name?

* 5. When is your employment anniversary (month and day only)?

* 6. In what year did you join the 100 Black Men of Madison?

* 7. Your Current, Complete Mailing Address

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