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* 1. First Name

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* 2. Last Name

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* 3. Company Email Address (We Do Not Sell or Share Your Email)

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* 4. Company

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* 5. Your Title

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* 6. Industry (ie Finance, Consulting, Technology, etc.)

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* 7. How did you hear about the 100K Mentors Initiative?

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* 8. Are you interested in pledging your company for the 100k Mentor Challenge

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* 9. In what other areas would you like to explore partnering?

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