Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

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Phone *

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Please check all that apply:

I am currently an ACTS Partner.

I have applied to become an ACTS Partner.

I am interested in becoming an ACTS Partner.

I am applying for a grant for the following goals:

Resources/Equipment

Cross Pollination Trip

An ACTS Summit

When do you need these funds?

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DD

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Do you have a way to receive funds if you are approved?

PayPal

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Other