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2. 
4. First Name*
5. Last Name*
7. Affiliation*
9. Email*
10. Phone*

    (555-555-5555)

12. Payment*

    Please indicate how the registration fee will be paid. Payment is due at the first session of the course. Checks should be made payable to "Montgomery County Treasurer." You may also pay with exact cash. 

    1. Registrant will pay by personal check or exact cash.
    2. Municipality/business/organization will provide check.
14. Name of Person Issuing Payment *
16. Email Address of Person Issuing Payment*
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18. 1. Receive an email copy of this form.
19. Email address

    This field is not part of the form submission.

20. Submit Submit and Print

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