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* 1. Your Name

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* 2. Email Address

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* 3. Industry

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* 4. Please provide a synopsis of your business.

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* 5. Are you interested in being mentored on an occasional or ongoing basis?

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* 6. What do you think your biggest issue is at the moment in business?

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* 7. Can you provide any more details that may help us match you with a mentor?

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