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* 1. First Name

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* 2. Last Name

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* 3. Email address (please provide the same email that you use for your MyNRMN account)

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* 4. Institution Name

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* 5. Major or Field of Study

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* 6. Highest Level of Education

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* 7. What is it about NRMN and its mission of enhancing diversity in the STEM fields that motivates you?

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