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Tuesday, 13 January 2009 22:20
* First Name:
* Last Name:
* Your email address:
Phone Number (numbers only):
I am willing to:









Address line 1:
Address line 2:
City:
State:
Zip code:
Are you any of the following:








Are you a medical marijuana patient:

If yes and you are comfortable doing so please share with us the illness and symptoms marijuana helps:
Would you be interested in telling your story, either publicly or anonymously to be published on our website?:

Business Phone (numbers only):
Cell Phone (numbers only):
Company Name (numbers only):

  		 

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Your Credit Card Statement will say Dallas Peace Center

Ministers/Churches/Civic Organizations can sign our
statement of compassion.