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Youth Ambassador Participation Form


*Full Name :


*Date of Birth :
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*Home Address:


*City:


*County:


*State:


*ZIP Code:


*Cell Phone :


*E-mail Address:


*Are you planning to participate in the contest Jan. 22-23, 2013?   :


If unable to participate in the contest, please briefly explain why :



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Iowa Pork Congress Program
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