Individual Information

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. What is the name of your organization?

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* 4. What is your age?

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* 5. What is your gender?

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* 6. Which race/ethnicity best describes you? (Please choose only one.)

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* 7. If you identify with multiple ethnicities, please specify:

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* 8. Street Address:

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* 9. City:

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* 10. State:

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* 11. Zip Code:

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* 12. What is your email address?

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* 13. Phone Number:

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* 14. What is your title?

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* 15. Please insert your LinkedIn profile link.

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* 16. Please insert your website.

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* 19. If you are not in the Chicagoland area, please tell us which city you are in:

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* 20. Primary contact (if different from above)

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* 22. What type of company or organization are you with?

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