MODERE MEETUP HOST REGISTRATION

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* 1. Please enter your name.

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* 2. Please enter your email address.

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* 3. Please enter your phone number.

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* 4. What is your Modere Meetup location address?

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* 5. What is your Modere Meetup registration link?

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* 6. What is the date and time of your Modere Meetup?

Date / Time

Date

Time

AM/PM

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* 7. Please upload a proof of attendance list. (This will be used to determine incentive eligibility.)

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

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* 8. I acknowledge that any cost associated with hosting my Modere Meetup will be at my own expense.

Yes