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We want your ideas and we need your help

Please print out this questionnaire and answer the following questions to give us your input:

1. Are you in a leadership position now?

Yes ___ No ___

If no , what do you need to move into leadership?

Mentoring ___

Education ___

Other (Please Specify) ____________

If yes , will you share your story with us?

Yes ___ No ___

2. Would like membership information?

Yes____ No____

3. Would you be willing to start a Fifty/Fifty Leadership Program in your area?

Yes___ No ___

Your additional comments, requests and suggestions are appreciated:

Your Name: ___________________________

Email: _______________________________

Phone: ______________________________

Please mail your questionnaire to:

Fifty/Fifty Leadership, P.O. Box 11202, Glendale, CA 91226

Or fax to: (818) 243-2601