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* 1. Please provide your full name.

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* 2. What company do you work for, and what is your title there?

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* 3. Where is your company located?

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* 4. Please provide your email address and phone number.

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* 5. Please provide a link to your LinkedIn profile.

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* 6. Which college or university did you attend?

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* 7. Please share the services that your company offers.

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* 8. Which chapter(s) are you interested in joining? (Click all that apply)

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* 9. Which membership level(s) are you interested in?

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* 10. Why would you like to join a BUILT chapter? What do you hope to gain from becoming part of the BUILT community?

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* 11. Please provide your birthdate (MM / DD / YYYY).

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* 12. Please provide your shirt size

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* 13. Please provide us with a good mailing address. 
We promise not send you spam, but we do occasionally send gifts to our members :)

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* 14. Please upload your company logo.

PNG file types only.
Choose File

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* 15. Please upload a headshot of your choice.

PNG, JPG, JPEG file types only.
Choose File

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* 16. Is there anything else you would like to share about yourself, your company, or your interest in BUILT?

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