Supporting Families Affected by Breast Cancer

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Over 2,000 mammograms
given away since 2017!

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Request to shop January 11!

Store Open From 11A -2P on Jan. 11 @ PUEBLO MALL

**Immediate Family Must Be Affected By Breast Cancer**

Limited to first 100 shoppers!

PLEASE FILL OUT FORM. DOUBLE CHECK EMAIL IS CORRECT!

Name*

Email*

Phone #*

Have you or anyone in your immediate family been diagnosed with breast cancer? Y or N.*

Can you provide docs that prove this diagnosis? Y or N.*

How many shoppers will be in your party?*

How many times have you shopped with us?

PLEASE MAKE SURE YOUR EMAIL ADDRESS IS CORRECT! PRESS "SEND" WHEN COMPLETED.

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WE LOOK FORWARD TO MEETING YOU!

The Becky Baker Foundation

Ofc: (719) 822-2328 • Mobile: (808) 333-4756

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