110th Town Hall Biographical Information
RequiredRequired Question(s)
Required 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:
Alternate E-mail address:
Home Address 1:
Home Address 2:
Home City:
Home Postal Code:
Home State:

Required 2.

In which Arizona county do you reside? 

 

50 characters left.
3.

Have you ever attended an Arizona Town Hall?

Yes
No
4.

Your education (where, when, degrees). 

 

350 characters left.
5.

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

 

350 characters left.
6.

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

 

350 characters left.
7.

If you are planning to bring guests to any of the Town Hall meal functions, please list their names below.

 

50 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 ethnicity.

African American
Asian, Pacific Islander
Caucasian
Hispanic/Latino
Native American/American Indian
Other
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
Arts & Entertainment
Utility
Organization, nonprofit
Retired, Community Volunteer
Student
Other  
12.

Here are some of the questions, ideas and issues that I would like to see discussed at the 110th Arizona Town Hall on Funding preK-12 Education. The discussion questions at the Town Hall will be drafted from participant submissions. 

 

1000 characters left.