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Record Clearing Clinic Pre-Registration
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Alias
*
(any name you may have been arrested using)
Your answer
Email Address
*
Your answer
Phone Number
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Do you have outstanding fines or fees?
Yes
No
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How Did You Hear About The Event?
*
Social Media (The Elevation Project Page)
Social Media (Mally Cobain)
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Word Of Mouth
Other:
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