Disruptor of The Year

Application

Full Name

Email Address

Phone Number

Organization/Company Name

Role/Title

Are you nominating yourself or someone else?

Self Someone else

Name of Nominee (if different)

Nominee’s Email (required if nominating someone else)

Nominee’s Organization/Company

What makes this nominee a disruptor? (required)

Describe the impact of their work. (required)

Industry or Field of Disruption

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