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* 1. Your name

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* 2. Your email address (we will send the curriculum for this tripartite event to this email).

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* 3. Your job title

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* 4. Name of your organization

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* 5. Your phone number

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* 6. What is the size of your organization?

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* 7. What are your main areas of responsibility?

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* 8. Based on the description, in what ways might this tripartite program (occurring over 6 months) be relevant for you and/or your organization?

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* 9. If we could wave a magic wand and have your biggest challenge go away, what would it be?

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* 10. What are your main professional and/or organizational goals for the next 12-24 months?

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