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Ms Moxxie Mentee Application - Year 1 Applicants Only

This group mentoring program resumes in mid-October 2021. It will be a hybrid program with virtual meetiings every two weeks and occasional in-person events. Each group is comprised of two co-mentors and 10 mentees. View the curriculum & meeting dates.

Note that if your application is approved, the PROGRAM FEE OF $650 must be made prior to the start of the program.

Personal Info

First Name:*

Last Name:*

Home Address:*

Home City:*

Home State:*

Home ZIP Code:*

Mobile Phone:*

Date of Birth:*

Personal Email:*

Professional Info

Company Name:*

Company Address:*

Company City:*

Company State:*

Company ZIP Code:*

Company Position:*

Company Phone:*

Company Email:*

Direct Supervisor Name:*

Direct Supervisor Title:*

Direct Supervisor Phone:*

Direct Supervisor Email:*

Group Meetings

Please check one or more preferences for your group meeting time:

8:00 AM12:00 PM

Your Goals

What are you hoping to learn from Ms Moxxie?

How did you hear about Ms Moxxie?

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