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Community Underwriting Intake Form

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Name of business or organization
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Name of authorized representative
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Title of authorized representative
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Address line 1
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Address line 2
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City
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Zipcode
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Contact Email for authorized representative
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Telephone contact information for authorized representative
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on-line contact point
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Products and/or services offered
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Location or service area
contact points on FB, IG, X, LinkedIn, TikTok, Discord, etc.
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Year founded or duration in business
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