Membership Information
1.
Please enter the information indicated below.
First Name:
Last Name:
Job Title:
Company Name:
Work Phone:
Home Phone:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province
(US/Canada):
Postal Code:

2.
Have you ever attended a Town Hall?
Yes
No
3.

Your place of birth.
 

  • 50 characters left.
4.

Your education (where, when, degrees).
 

  • 350 characters left.
5.

The Arizona Town Hall sends monthly newsletters and various informational notices to its members.  How would you prefer to receive these items?
via e-mail
via U.S. Postal Service
6.

List the civic and cultural organizations in which you currently participate, including any offices held.
 

  • 350 characters left.
7.

List the civic and cultural organizations in which you have participated in the past, including offices held. 
 

  • 350 characters left.

Completion of the following questions will assist in grouping participants in a manner that best represents a diverse cross-section of stakeholders.
 
8.

Your gender.
Female
Male
9.

Your ethnic group.
American Indian
Black
Caucasian
Hispanic
Other
Unknown
10.

Your age group.
18 - 30
31 - 45
46 - 65
Over 65
11.

Your occupational categories (list all that apply).
State Legislature
Government Official, elected
Government/Public Official or Agency Representative, appointed
Agriculture, Farming, Ranching
Attorney
Judiciary, Courts
Builder, Developer, Realtor
Business, General
Clergy, Faith-based Organization
Education
Environment, Conservation
Financial
Health Care
Labor
Media, Communications
Mining
Utility
Organization, nonprofit
Retired, Community Volunteer
Student
Other