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* 1. Name of experienced committee member:

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* 2. Email address of experienced committee member:

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* 3. Phone number (cell phone preferred as this will be how the mentee gets a hold of you during the conference):

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* 4. Employer:

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* 5. Position, professional role, or job title:

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* 6. Brief description of your current job:

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* 7. Your employer's association membership type:

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* 8. Service and/or products your employer produces:

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* 9. Committee(s) you participate in:

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