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Eligibility Exception

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Your legal name

Your email address

Please Confirm full name and signature.

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I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Timestamp

Audit

10/04/2022 4:11 pm CST

Eligibility Exception Uploaded by Adam Jacobi - office@wisdaa.org IP 207.153.30.135