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Candidate Interest Card

  1. Personal Information

  2. (MM/DD/YYYY)

  3. Check yes if you would like to be included in our mailing list.

  4. Referral Information

  5. Referral Details

  6. Please list the name or date of event

  7. Please list the specific media venue (i.e., KARV, KCJC, River Valley Leader, Courier, etc.)

  8. Please list the specific site or URL

  9. Qualifying Information

  10. Leave This Blank:

  11. This field is not part of the form submission.