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:

Your Goals

What are you hoping to learn from Ms Moxxie?

How did you hear about Ms Moxxie?

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