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    22nd Annual Mid-Winter Fire School, Holdrege, NE
    This form is on a secure Website for the protection of your information.
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    Last Name:
    First Name:
    Middle Initial:
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    Home Address:
    City:
    State:
    Zip
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    Social Security or CCC ID #
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    Birthdate: (mm/dd/yyyy)
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    Home Phone:
    Cell Phone:
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    E-Mail:
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    Fire Department:
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    Please indicate your 1st, 2nd, and 3rd choices for classes from the lists below.
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    1st Choice
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    2nd Choice
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    3rd Choice
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    Bill My Agency: Complete the following information and we will Invoice your Agency.
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    Contact Person:
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    Organization:
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    Mailing Address:
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    City:
    State:
    Zip.
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    You will receive an immediate e-mail confirmation of registration.
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