To type on and submit this form you will need to have the latest updates of Adobe Acrobat Reader and install the newest version of the Acrobat plug-in for your browser.
If you cannot type on this form and/or cannot click to send, please SAVE the file to your computer. You can then fill out the form and then SCAN and EMAIL it to Kimberly Kaufer (email@example.com) or send to the attention of Kimberly Kaufer via FAX at 631.447.3347
Please confirm with the appropriate contact to ensure it was received!
If you are having problems viewing this page, please download the latest version of Adobe Acrobat Reader and install the newest version of the Acrobat plug-in for your browser. This is a free download.