* 1. Name (inc. Maiden name):

* 2. *AVC Degree/Program:

* 3. Year:

* 4. Spouse/Partner:

* 5. Gender:

* 6. Do you have children?

* 7. Preferred Mailing Address:

* 8. Company:

* 9. Title:

* 10. Job Function:

* 11. Industry:

* 12. Business:

* 13. Home:

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