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* 1. Your Name

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* 2. Your Role

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* 3. Your Org

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* 4. Email so we can contact you

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* 6. Your location (time zone consideration)

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* 7. Which department do you report into?

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* 8. Why do you want to join a CX Leader Roundtable?

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* 9. Anything you want to us to know about your interest for joining the CX Leader Roundtable?

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