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2. Name*
4. Name to print/recognize:
6. Email*
7. Phone*
9. Firework Donation*

   1. Corporate $500+
   2. Patriots $100-$499
   3. Firecrackers $50-$99
   4. Sparkler $49 or less
   5. Other
10. Donation amount*

    Indicate your donation amount.  You will receive an invoice by email. 

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11. 1. Receive an email copy of this form.
12. Email address

    This field is not part of the form submission.

13. Submit Submit and Print

* indicates a required field