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ABOUT THE NOMINEE
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ABOUT YOU
First Name
Last Name
Gender
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Date of Birth
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Email
Phone
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Country of Residence
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Afghanistan
Albania
Algeria
Andorra
Angola
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahrain
Bangladesh
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Botswana
Brazil
Bulgaria
Burkina Faso
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Congo
Costa Rica
Côte d'Ivoire
Croatia
Cyprus
Czech Republic
Denmark
Djibouti
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Greenland
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Korea, South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Macedonia
Madagascar
Malawi
Malaysia
Mali
Mauritania
Mexico
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Pakistan
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Romania
Russia
Rwanda
Saudi Arabia
Senegal
Serbia
Sierra Leone
Singapore
Slovakia
Slovenia
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tanzania
Thailand
Tunisia
Turkey
Turkmenistan
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
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AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
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VT
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Ontario
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State / Province
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20 characters left.
Education level
Name of your Changemaker Initiative
What field/area is your initiative focused on?
What is the problem you are trying to address?
250 words remaining
What is your idea to address the problem?
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How long have you been working on this problem?
Do you work with a team?
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How many fully committed team members do you have?
How does your team support you in reaching your goals?
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What impact have you had to date?
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How many people have been impacted by your idea (approximately)?
You are a Changemaker… What are you ideas to help other young people become Changemakers like you?
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Please share any links that you might have that contain stories, profile, news, or any information about you and your work.
Any other things you want us to know?
500 words remaining
Should we send you periodic updates about Ashoka & opportunities to engage?
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