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Name of Organization:
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Address:
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Are you a non-profit organization?
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Do you have 501 (c)(3) status?
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Hours of Operation:
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Eligibility:
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Services Provided:
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Summary of Services:
Remarks:
We agree to join the Priority Male Empowerment Network, and to accept referral for services provided by our agency/organization.

Signed:__________________________ Position:______________________________________ Date:__________________