* 1. What is your name?

* 2. Will you attend Women's Political Leadership in Massachusetts: A Panel Discussion on Thursday, November 15, to be held at the University of Massachusetts Boston from 6:00 to 8:00 pm?

* 3. What is your affiliation, if any?

* 4. What is your email address?

* 5. Do you require special accommodations to attend this event?

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