Application for Participation in an Arizona Town Hall
1.

Please enter the information indicated below.  This information will be used to create biographies that will be distributed to all participants.


By entering my personal information, I consent to receive email communications from the survey author's organization based on the information collected.

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.

 

50 characters left.
5.

Your education (where, when, degrees).

 

350 characters left.
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 for each panel.

 
8.

Your gender.

Female
Male
9.

Your ethnic group.

African American
Asian, Pacific Islander
Caucasian
Hispanic
Native American
Other
10.

Your age group.

18 - 30
31 - 45
46 - 65
Over 65
11.

Your occupational categories (list all that apply).

Arts, Entertainment and Recreation
Government Official, elected or appointed
Community Volunteer
Agriculture, Farming, Ranching
Legal Services, Attorney, Judge
Judiciary, Courts
Builder, Developer, Architect, Realtor, Construction
Business, General
Clergy, Faith-based Organization
Education
Environment, Conservation
Financial Services
Health Care
Tourism Industry
News Media, Communications
Mining
Utility
Nonprofit
Retired
Student
Other  
12.

With regard to the future of Arizona, what ideas, topics or issues do you believe are the most important to the state?  *Some examples might include issues relating to education, workforce development, attainable/workforce housing, transportation, water, health care, land use, or arts and culture.   

 

350 characters left.