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* 1. First Name

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* 2. Last Name

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* 3. Credentials and Designations

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* 4. Current Organization

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* 5. Current Title

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* 6. Organization Type

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* 7. Work Email

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* 8. Personal Email

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* 9. Work Phone

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* 10. Mobile Phone

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* 11. LinkedIn Profile

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* 12. What topic(s) are you qualified and interested in speaking about?

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* 13. Please provide details about the topics you are interested in being considered to present.

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