Operator Membership

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First Name: *
Middle Initial:
Last Name: *
Home Phone Number: *
	Example: 011 52 755 (225 8199) International (520) 123-1234 Domestic
Cell Phone Number:
Work Phone Number:
Mailing Address: *
Mailing Address:
City: *	Mailing Address
State/Province: *	Mailing Address
Postal code/Zip: *	Mailing Address
Country: *	Mailing Address
	Email address is important as this is the address prospective residents will contact you.
E-mail address: *

Current occupation: *
Date to open your retreat:*
General location of your retreat? City,state/prov, region, country:*
Field of Interest: *	Fiction Nonfiction Playwriting Screenwriting Filmmaking Poetry Others

Comments (n/a if not applicable): *

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