Young Professionals Leadership Development Application

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* 1. General Information:

Name

Company

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Are you under the age of 35?

Yes

No

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* 3. Do you have a start-up business that has been in existence less than 2 years?

Yes

No

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* 4. If you do have a start-up business, please list your business below in the comment box:

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* 5. Can you provide proof of your business incorporation date? Please write the date below in the comment box.

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* 6. Are you a young professional that works for an SIEDC member business?

Yes

No

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* 7. If you do work for an SIEDC member business, please list it below in the comment box:

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* 8. If you do work for a SIEDC member business, please choose their membership level below:

Board Member

Cabinet Member

Business Council Member

Executive Women's Counil

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* 9. Do you live on Staten Island?

Yes

No

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* 10. Do you work on Staten Island?

Yes

No