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2. Store Name*
4. Store Website
6. Store Phone Number*
8. Do you offer*

   1. Touchless Payments
   2. Payment by Phone
   3. Phone Shopping Assistance
   4. Curbside Pickup
   5. Delivery
   6. Senior Shopping Hours
   7. Senior Discounts
10. Your Name*
12. Your Email Address (in Case We Have Questions)*
14. Comments
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16. 1. Receive an email copy of this form.
17. Email address

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18. Submit

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