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NJPFVC Intake
Please share your story, indicate your district/county/zip and if you are willing to share
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Your reason for wanting a virtual option
Your answer
Are you willing to share your story with legislators or the media?
Yes, I am willing to share my story
No but you can include my reasons why when speaking about the need
Please indicate your District, County and Zip Code (Some districts have the same name as other counties; we cannot decipher so we will need for you to input this information into this form)
Your answer
If you answered YES to question 2 Please provide your first name and email address so we can follow up with you.
Your answer
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