Ms Moxxie Application

The 2019 Ms Moxxie program runs from May through December.  You may complete the application for the 2019 program any time before May 2019.  Feel free to email us with any questions at info@moxxiementoring.org

Personal Info

First Name:*
Last Name:*
Home Address:*
Home City:*
Home State:*
Home ZIP Code:*
Mobile Phone:*
Date of Birth:*

Professional Info

Company Name:*
Company Address:*
Company City:*
Company State:*
Company ZIP Code:*
Company Position:*
Company Phone:*
Company Email:*

Group Meetings

Meetings take place from 8:00 - 9:30 AM. Year 1 groups meet once every three weeks from May through December. Meeting locations are in Nassau, Suffolk and Mid-Island. Which location is most convenient to your home or work?

NOTE: - We may be adding an evening group in Melville. Please check if you prefer this.

Your Goals

What are you hoping to learn from Ms Moxxie?

How did you hear about Ms Moxxie?

Program Fee - $625.00

NOTE - Fee must be remitted BEFORE the beginning of the program in May.

Payment

Check - please make check payable and mail to:

Moxxie Mentoring Foundation Inc
107 Wohseepee Drive
Brightwaters, NY 11718

If you require an invoice, please click HERE to contact us.

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