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NAME

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ADDRESS


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CITY/STATE/ZIP


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HOME EMAIL


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PLACE OF WORK


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WORK ADDRESS


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CITY/STATE/ZIP


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WORK TELEPHONE #


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WORK EMAIL


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GRADES/SUBJECTS TAUGHT


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Mail the completed form with you check for $15.00
to Connie Mason, ACSS Treasurer: P. O. Box 124, Lonoke, AR 72086.

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