| First Name:* |
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| Last Name:* |
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| Business Name: |
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| Address:* |
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| City/State/Zip:* |
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| Business Website: |
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| Email:* |
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| Primary Phone:* |
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| Cell Phone: |
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| Fax: |
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Please check all that apply:
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Any suggestions/observations about the Main Street program?
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How would you like to pay?
Credit Card Online (PayPal) Check
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Select Membership Type:
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If you selected the "Friend" membership level,
please enter the amount of your donation:
note: minimum amount is $25, do not use the $ sign (i.e. 50 not $50)
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