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* 1. What is your first name?

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* 2. What is your last name?

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* 3. Where do you work?

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* 4. What is your email address?

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* 5. What is your phone number?

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* 6. If you are a member of an equity-seeking group, please indicate below:

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* 7. Tell us about yourself and why you want to attend our weekend education program in 2-3 paragraphs.

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