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* 1. What is your name? If you prefer to be anonymous leave this blank.

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* 2. What is your email address?

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* 3. If you do not use email - what is your phone number or another way I can contact you?

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* 4. Please tell me your story, advice, suggestion, or question. This does not have to be polished - if I decide to use your contribution in the book I will contact you and we can craft the final version together. 

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* 5. Do you want to receive updates about the book?

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