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* 1. What is your full name?

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* 2. Please provide your email:

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* 3. What is your affiliation with Vanderbilt? (Class Year, School, Degree) 

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* 4. What is the name of your business?

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* 5. What is your title in the business?

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* 6. In what year was your business founded?

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* 7. What stage is your business in?

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* 8. Please provide a brief description of the product or service your business provides:

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* 9. Please provide any recent business successes you would like to share. No matter how big or small, the C4E wants to recognize your business's successes!

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* 10. Please upload an image of yourself and any images of your business you would like us to share

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* 11. By checking this box you consent to C4E using this information in our newsletter, social media, and website

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* 12. Please check this box if you are willing to be contacted by the C4E to set up an interview on you and your business. 

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