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2. For items that are not applicable, enter 'N/A'

4. First and Last Name*
6. Email Address*
8. Mailing Address*
10. City*
11. State*
12. Zip Code*
14. Phone Number*
15. Alternate Phone Number
17. Petitioner*
18. Respondent*
20. Case Number*
24. Is an Order or Protection Currently in Effect?*

    1. Yes
    2. No
    3. N/A
25. Any Other Safety Issues or Concerns?
27. Do You Have a Fee Waiver or Deferral from the Court?

    1. Yes
    2. No
29. Do You Require the Assistance of an Interpreter?*

    1. Yes
    2. No
30. What Language?
32. Would You Like to Receive Class Material in Spanish?*

    1. Yes
    2. No
33. Are you Request to Complete the Class Via DVD or Online?

    1. DVD
    2. Online
35. Would You like to Receive an Automated Reminder of This Class by Phone?*

    1. Yes
    2. No

    Reminder calls are done the Wednesday prior to the class.

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37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field