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Ast Name First Name Middle Home Mailing Address Email Address (school email required) City, State Zip Home Phone Have you ever been a member of the Collaborative? No Yes, during (year) Highest Education Level: Bachelor Masters Doctorate Gender: M F Ethnicity: African American Asian-American Caucasian Hispanic Other Computer Used at SCHOOL : Mac PC None Computer Used at HOME: Certificate Teaching Level: PK-5 6-8 9-12 Years.

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