96th Town Hall Biographical Information
1.

Please enter the information indicated below.  This information will be used to create biographies that will be distributed to all participants.
First Name:
Middle Name:
Last Name:
Job Title:
Company Name:
Work Phone:
Home Phone:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
Address 3:
City:
State/Province
(US/Canada):
Postal Code:

2.

In which county do you reside?
 

  • 50 characters left.
3.
Have you ever attended a Town Hall?
Yes
No
4.

Your place of birth.
 

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5.

Your education (where, when, degrees).
 

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6.

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

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7.

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

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8.

Please list the names of guests who will be accompanying you at any Town Hall meal functions.
 

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Completion of the following questions will assist in grouping participants in a manner that best represents a diverse cross-section of stakeholders for each panel.
 
9.

Your gender.
Female
Male
10.

Your ethnic group.
African American
Asian, Pacific Islander
Caucasian
Hispanic
Native American
Other
11.

Your age group.
18 - 30
31 - 45
46 - 65
Over 65
12.

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  
13.

Here are some of the questions, ideas and issues that I would like to see discussed at the 96th Arizona Town Hall on economic development.
 

  • 350 characters left.