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Medicare for All
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My Record of Participants


This page is designed to be printed, which is why it may look bad on the screen.

      Name                            Address                                 E-Mail Address                   Phone number

1___________________ __________________________ ___________________ ____________


2___________________ __________________________ ___________________ ____________


3___________________ __________________________ ___________________ ____________


4___________________ __________________________ ___________________ ____________


5___________________ __________________________ ___________________ ____________


6___________________ __________________________ ___________________ ____________


7___________________ __________________________ ___________________ ____________


8___________________ __________________________ ___________________ ____________


9___________________ __________________________ ___________________ ____________


10__________________ __________________________ ___________________ ____________

Consider writing the date of initial contact under the person’s name.

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