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2. Disclaimer:
   Anyone who submits a form should be aware that in accordance with the North Carolina Public Records law, found in North Carolina General Stautes Chapter132, his or her e-mail address is considered public record.
4. Need help with this form? Call 336-434-3134
6. First Name
7. Last Name
9. Address
11. City
12. State
13. Zip Code
15. Phone Number
16. If you wished to be contacted:

    1. phone number
    2. email
18. Email Address
22. Comments:
24. If an Emergency, call 911
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26. 1. Receive an email copy of this form.
27. Email address

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28. Submit

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