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AGENCY NAME _________________________________ ADDRESS _________________________________ PHONE # _________________________________ E-MAIL ADDRESS _________________________________ CONTACT PERSON ________________________________ MEMBERSHIP FEE $15.00 PER AGENCY (Checks to be made out to Lackawanna County Interagency Council) RECEIPT: AGENCY ___________________ DATE ___________________ Thank you, Lackawanna County Interagency Council Mail Registration and check to:
Joanne Stephens
St. Joseph’s Center
2010 Adams Ave. Scranton, PA 18509
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Copyright 2005. |
