Please complete the form below to provide information concerning your interest in Public Health Solutions.
| Basic Information: |
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| First Name: |
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| Last Name: |
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| Mailing Address: |
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| City: |
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| State: |
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| Zip: |
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| Phone: |
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| Cell Phone: |
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| E-mail Address: |
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| For this one year trial peroid (ending June 30, 2010) do you want to adopt a stream as an individual or a group? |
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| Group Information: |
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| If you are applying to adopt as a group, complete the following: |
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| Name of the group: |
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| National or state affiliation, if any: |
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| Mailing address of the group: |
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| Email address of the group: |
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| Advanced Information: |
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| Do you or anyone in your group have experience with water quality monitoring? |
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| If so list their names: |
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| Which Nebraska county do you live in?
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| Have you identified a stream, lake, pond, or wetland you would like to adopt? If so, please include its name and the location where you would sample. Please provide GPS coordinates, or description such as "the highway 33, bridge across, the Blue River in Crete." (If you have not already identified a location to adopt, we can help you find one). |
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